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6491 


CLINICAL  LECTURES 

ON 

INFANT  FEEDING 


'Boston  Methods 

by 

LEWIS  WEBB  HILL,  M.D. 

Junior  Assistant  Visiting  Physician,  Children's  Hospital,  Boston;  Alumni 
Assistant  in  Pediatrics,  Harvard  Medical  School 


Chicago  Methods 

by 

JESSE  ROBERT  GERSTLEY,  M.D. 

Instructor  in  Pediatrics,  Northwestern  University  Medical  School;  Associate 
Attending  Pediatrician,  Michael  Reese  Hospital,  Chicago 


PHILADELPHIA  AND  LONDON 

W.   B.  SAUNDERS    COMPANY 
1917 


Copyright,  1917,  by  W.  B.  Saunders  C!ompany 


PRINTED  IN  AMERICA 


PRESS  OF 

W.  B.  SAUNDERS  COMPANY 

PHILADELPHIA 


ujs 
no 

PREFACE 

As  these  lectures  represent  a  somewhat  new  method  of  post- 
graduate medical  education  in  this  country,  the  history  leading 
to  their  development  may  be  of  interest.  The  plan  originated 
with  Dr.  W.  S.  Rankin,  Secretary  of  the  Board  of  Health  of  the 
State  of  North  Carolina.  He  conceived  the  idea  of  bringing 
the  medical  school,  in  the  person  of  a  traveling  lecturer,  to  the 
doors  of  the  physician,  enabling  the  latter  in  this  way  to  con- 
tinue with  his  practice  instead  of  being  compelled  to  leave  it 
for  several  months  while  he  sought  postgraduate  education  in 
one  of  the  large  medical  centers.  Upon  hearing  of  this  scheme. 
President  E.  K.  Graham,  of  the  University  of  North  CaroUna, 
gave  it  his  enthusiastic  support,  and  courses  were  arranged 
under  the  joint  auspices  of  the  University  and  the  State  Board  of 
Health.  Two  sections  of  six  classes  each  were  organized,  one 
in  the  eastern  part  of  the  State,  one  in  the  western.  Each  of 
us  had  six  towns  in  his  circuit,  and  traveled  each  day  to  a  new 
town,  returning  to  the  first  one  at  the  beginning  of  each  week. 
One  of  us  was  trained  in  the  methods  used  in  Boston,  the 
other  in  Chicago,  with  postgraduate  work  in  Europe.  As  a 
result  of  this  dissimilarity  in  our  training  the  lectures  differ  a 
good  deal,  and  it  occurred  to  us  that  it  might  be  of  value  to 
combine  the  two  sets  in  one  volume,  so  that  the  teachings  of  two 
^  somewhat  different  schools  of  infant  feeding  may  be  compared. 
Vy^  Each  of  us  has  prepared  and  presented  his  course  of  lectures 

L^       independently  of  the  other  and  without  knowledge  of  the  other's 
^        methods  and  plans.     It  is  with  a  spirit  of  cooperation  rather 
(;;i       than  rivalry,  of  construction  than  destruction,  that  we  offer 
^        them  to  the  profession. 


.V^ 


Lewis  Webb  Hill 

Jesse  R.  Gerstley 
September,  1917 


11 


624304 


CONTENTS 


CLINICAL  LECTURES  ON  INFANT  FEEDING 
(BOSTON  METHODS) 

By  lewis  WEBB  HILL,  M.D. 

LECTURE  I 

Intkoduction  to  Feeding  in  General 17 

Breast  Feeding 21 

Artificial  Feeding 27 

LECTURE  II 

The  Modification  of  Milk 31 

LECTURE  III 

The  Feeding  of  Normal  Infants 41 

The  Proprietary  Foods 49 

Premature  Infants 56 

LECTURE  IV 

Difficult  Feeding  Cases 59 

Disturbances  of  Digestion 61 

The  Various  Types  of  Indigestion 61 

The  Stools  in  Infancy 70 

Constipation 73 

LECTURE  V 

Diarrheas  of  Infancy 76 

Nervous  Diarrhea 77 

Mechanical  Diarrhea 77 

Fermentative  Diarrhea 77 

Infectious  Diarrhea 83 

LECTURE  VI 

Pyloric  Stenosis 91 

Pyloric  Spasm 93 

Intussusception 95 

Acidosis 98 

13 


14  CONTENTS 

LECTURE  VII  PAGE 

Rickets 104 

Scurvy 107 

Spasmophilia Ill 

Clinics • 116 

CLINICAL  LECTURES  ON  INFANT  FEEDING 
(CHICAGO  METHODS) 

Bt  JESSE  R.  GERSTLEY,  M.D. 

LECTURE  I 

Introduction 151 

Milk 152 

LECTURE  II 

Digestion  of  Milk 163 

Energy  of  Foods 176 

LECTURE  III 
Modern  Conception  of  Disturbances  of  Nutrition 178 

LECTURE  IV 
Failure  to  Gain 193 

LECTURE  V 
The  States  of  Dyspepsia  and  Intoxication 205 

LECTURE  VI 
Decomposition 224 

LECTURE  VII 
Parenteral  and  Enteral  Infections 242 

LECTURE  VIII 
Artificial  Feeding  of  the  Normal  Infant  . 256 

LECTURE  IX 
Breast  Feeding 270 

LECTURE  X 

Disturbances  in  the  Breast  Fed 280 

Clinics 293 

Conclusion 366 


Index 369 


CLINICAL  LECTURES 

ON 

INFANT  FEEDING 

Boston  Methods 

BY 
LEWIS  WEBB  HILL,  M.D. 


CLINICAL  LECTURES  ON  INFANT  FEEDING 

(BOSTON  METHODS) 


LECTURE  I* 
INTRODUCTION  TO  FEEDING  IN  GENERAL 

Pediatrics,  or  the  study  of  diseases  of  children,  is  naturally 
divided  into  a  number  of  sections,  of  which  the  most  important 
is  the  feeding  of  infants  and  the  treatment  of  the  diarrheal  dis- 
eases of  infancy. 

My  lecture  today  is  somewhat  of  an  introductory  lecture, 
taking  up  breast  feeding  and  a  short  introduction  to  artificial 
feeding.  It  is  my  purpose  to  make  these  lectures  as  practical 
as  possible,  and  to  touch  upon  theory  and  chemistry  only  so 
much  as  is  absolutely  necessary — as  I  am  fully  aware  that  you 
are  a  practical  group  of  men,  dealing  every  day  with  sick  people, 
and  not  with  theories,  chemical  names,  and  formulae.  It  is, 
however,  necessary  for  us  to  consider  a  few  fundamental  chemi- 
cal facts  upon  which  modern  infant  feeding  is  based  before  we 
can  go  on  to  the  more  practical  portion  of  the  subject. 

I  am  going  to  teach  you  ''percentage  feeding,"  which  is  used 
more  in  Boston  than  in  any  other  city.  In  the  old  days  of  infant 
feeding  there  was  no  science  of  any  sort ;  a  little  milk  and  water 
was  mixed  and  fed  to  the  baby,  without  knowing  what  he  was 
getting  of  food  value;  of  fat,  sugar,  and  protein.  Some  babies 
got  along  very  well  on  this,  but  as  you  know  some  will  get  along 
on  almost  anything,  whereas  some  need  the  utmost  care. 

Dr.  T.  Morgan  Rotch,  of  Boston,  about  twenty-five  years 
ago,  devised  the  so-called  percentage  method.  This  means  that 
in  a  baby's  milk  certain  elements  have  to  be  recognized.     The 

*  Sixteen  lectures  were  given  in  the  course.   The  other  nine  lectures  dealt 
with  the  general  diseases  of  children. 
2  .  17 


18  INFANT   FEEDING    (BOSTON  METHODS) 

food  elements  of  milk  are,  as  you  know,  fat,  sugar,  and  protein, 
and  it  is  desirable  to  know  how  much  of  each  the  infant  is  get- 
ting, because  digestive  disturbances  of  all  sorts  are  likely  to  be 
due  to  too  much  or  too  little  of  one  element  or  the  other  in  the 
milk.  These  ideas  simplify  the  whole  matter  of  feeding  because 
the  physician  can  tell  so  easily  with  what  he  is  dealing.  There 
is  no  reason  why  a  baby  should  not  have  its  milk  made  up  in 
just  as  accurate  a  way  as  a  prescription  is  made  up.  With  adults 
it  is  not  necessary  to  regulate  the  food  so  carefully,  because  an 
adult's  digestion  is  stronger,  and  small  things  will  not  upset  it 
so  easily.  The  percentage  method  of  feeding  consists  simply  in 
writing  a  prescription  for  the  baby's  milk  according  to  the  in- 
dications, knowing  approximately  how  much  of  each  food  ele- 
ment the  prescription  contains,  the  most  convenient  way  of 
expressing  the  quantity  of  these  elements  being  in  percentages. 
As  an  introduction,  I  think  I  cannot  do  better  than  to  read  a 
few  lines  written  a  short  time  ago  by  Dr.  Ladd,  of  Boston : 

"Now,  whatever  our  method  of  making  a  food  for  infants,  in  which  milk 
is  the  basis,  we  are  making  a  modified  milk  containing  certain  percentages 
of  the  elements.  Percentage  feeding  presupposes  that  these  alterations 
have  been  made  by  the  physician  with  design  and  with  a  definite  knowledge 
of  the  end-result  of  his  changes.  By  the  old  method  milk  was  modified 
quite  as  much  as  by  modern  methods,  but  with  this  fundamental  difference : 
that  the  physician  had  not  the  slightest  conception  of  the  composition  of 
his  mixture,  and  hence  no  check  upon  his  results.  Without  a  knowledge 
of  the  percentage  composition  of  the  milk  it  is  next  to  impossible  to  give  a 
lucid  and  intelligent  expression  of  its  food  value.  A  mixture  expressed  as 
so  many  ounces  of  cream,  milk,  lime-water,  sugar,  and  water  may  exactly 
fulfil  the  requirements  of  an  individual  infant,  but  unless  I  can  express  such 
a  formula  to  a  student  in  percentages  or  calories,  or  both,  my  exposition  of 
the  principles  on  which  I  have  acted  in  prescribing  such  a  formula  is  vague 
and  indefinite. 

"Whatever  we  may  feel  about  the  relative  values  of  fats  and  sugars  and 
proteins,  and  the  proportions  best  suited  to  individual  conditions,  the  per- 
centage method  of  thinking,  writing,  and  prescribing  should  not  and  does 
not  complicate  the  question.  In  fact,  it  simplifies  it  enormously,  for  it 
furnishes  us  the  means  for  accurate  estimation  of  food  values,  and  only  by 
such  knowledge  can  we  intelligently  check  up  oiu-  results  when  struggling 
with  the  problem  of  adapting  a  food  to  the  individual  requirements  of  an 
infant. 

"If  one  will  grasp  this  simple  idea  of  percentage  feeding,  one  will  dis- 
abuse one's  mind  of  the  conception,  so  erroneously  held,  that  percentage 
feeding  is  ultra-scientific,  very  mathematical,  complex,  and  impractical 
for  the  average  practitioner. 

"I  wish  to  emphasize  the  fact  that  the  purpose  of  percentage  feeding  is, 
on  the  contrary,  to  simplify  the  sometimes  very  difficult  question  of  finding 


INTRODUCTION   TO   FEEDING   IN  GENERAL  19 

a  food  which  the  infant  will  digest  and  upon  which  it  will  gain  normally  in 
development.  The  mathematics  involved  in  the  calculation  of  percentages 
are  of  the  simplest — a  mere  matter  of  proportions.  If  properly  presented, 
any  one  of  half  a  dozen  in  vogtte-is  easily  mastered  and  perfectly  practical. 
It  does  not  matter  by  whose  methods  one  works  to  gain  this  fundamental 
knowledge  of  how  to  calculate  the  percentage  elements  of  the  food,  so  long 
as  that  method  is  thoroughly  mastered.  Some  methods  are  simpler  to 
understand  than  others,  and  any  method  requires  some  study  and  practice, 
but  this  hardly  offers  an  excuse  for  ignorance  of  the  subject.  Any  third- 
year  medical  student  may  in  two  hours  be  taught  a  practical  way  of  calcu- 
lating percentages  and  estimating  the  caloric  value  of  any  mixture.  Such 
knowledge  is  rudimentary  but  fundamental.  Any  physician  who  pretends 
to  feed  scientifically  should  not  shim  the  task  of  acquiring  this  knowledge, 
any  more  than  he  should  avoid  the  labor  involved  in  grasping  the  technic 
of  simple  surgical  or  bacteriological  procedures,  in  order  to  become  more 
skilled  in  the  practice  of  modern  medicine.  Too  much  is  written  of  the 
difficulties  of  these  methods  of  calculation  by  men  who  have  been  too  lazy 
or  indifferent  to  learn  them ;  too  little  has  been  written  about  the  responsi- 
bility of  the  physician  to  master  them  in  order  to  become  a  more  efficient 
worker  along  the  lines  of  modern  infant  feeding." 

That  is  a  very  good  summing  up  of  the  question  of  percent- 
age feeding.  In  a  nutshell,  it  is  necessary  to  know,  in  any  milk 
mixture  which  is  being  fed  to  a  baby,  approximately  how  much  fat, 
how  much  protein,  and  how  much  sugar  it  contains. 

In  order  to  do  this  it  is  necessary  to  know  the  composition  of 
milk. 

Human  milk  contains  4  percent  of  fat,  7  percent  of  sugar, 
1.6  percent  of  protein,  and  about  0.2  percent  of  salts.  Cow's 
milk  contains  4  percent  of  fat,  4.5  percent  of  sugar,  3.2*  percent 
protein,  and  0.7  percent  salts.  Now,  different  specimens  of 
human  milk  vary  a  great  deal.  Different  cows'  milks  also  vary 
a  great  deal,  but  these  are  the  average  figures. 

Besides  the  quantitative  differences,  there  are  also  certain 
qualitative  differences.  The  fat  in  the  milk  is  in  the  form  of  an 
emulsion;  the  sugar,  protein,  and  salts  are  in  solution.  The 
globules  of  fat  in  cow's  milk  are  much  larger  than  in  human  milk. 
The  sugars  are  exactly  the  same. 

In  all  milks  there  are  two  kinds  of  proteins — casein  and  al- 
bumin or  whey  protein.  In  human  milk  there  is  more  whey 
protein  than  casein.  The  ratio  is  about  three  to  one.  In  cow's 
milk  there  is  more  casein  than  whey,  and  this  is  one  reason  why 

*  These  figures  are  not  absolutely  correct,  but  are  near  enough  for  practi- 
cal purposes. 


20'  INFANT   FEEDING    (BOSTON   METHODS) 

cow's  milk  is  so  much  harder  to  digest,  because  the  casein  pro- 
tein is  coagulated  in  the  stomach  into  tough  curds.  The  whey 
protein  is  not.  The  salts  are  qualitatively  about  the  same  in 
both  milks,  the  most  important  being  salts  of  sodium,  potas- 
sium, magnesium,  calcium,  iron,  phosphorus,  and  sulphur. 
The  salts  are  of  extreme  importance  in  the  nutrition  of  every 
baby,  but  we  cannot  take  them  into  practical  quantitative 
consideration  in  feeding  a  baby,  so  let  us  consider  the  three 
elements — fat,  sugar,  and  protein.  It  is  very  important  to 
bear  in  mind  this  composition  of  milk. 

Now  I  want  to  run  over  very  briefly  the  digestion  of  the 
different  food  elements.  First,  the  fat — it  is  not  acted  upon  to 
any  great  extent  in  the  stomach.  Chemically  it  consists  of  a 
fatty  acid  in  combination  with  glycerin,  forming  a  so-called 
"neutral"  fat.  After  leaving  the  stomach  it  enters  the  intes- 
tine, where  it  is  split  by  the  pancreatic  juice  into  glycerin  and  a 
fatty  acid.  The  fatty  acid  combines  with  an  alkali  in  the  in- 
testine, forming  a  "soap."  This  is  acted  upon  by  the  bile, 
which  emulsifies  it,  and  it  is  then  absorbed.  The  absorption  of 
fat  is  usually  very  good.  Often  90  or  95  percent  of  the  fat 
taken  in  will  be  absorbed  by  a  well  baby.  In  other  cases  as 
little  as  30  or  40  percent  will  be  absorbed,  and  most  of  the  fat 
will  come  out  in  the  stool  in  the  form  of  "soaps." 

The  sugar  is  acted  upon  very  Uttle  in  the  stomach.  Milk- 
sugar  is  what  is  known  as  a  disaccharid,  that  is,  a  complex  sugar. 
In  the  intestine  it  is  split  into  simpler  sugars  and  absorbed  as 
such.  The  absorption  of  sugar  is  usually  extremely  good,  and 
it  is  very  rare  to  find  any  in  the  stools  of  infants.  Sugar  may 
sometimes  remain  in  the  intestine,  and  may  be  broken  up  by  the 
bacteria  in  the  intestine  into  acids,  as  acetic  acid  and  butyric 
acid.     Fats  may  also  be  broken  up  in  this  way. 

Next  comes  protein.  Protein  is  partly  digested  in  the  stom- 
ach, where  it  is  coagulated  by  the  gastric  juices.  Digestion  is 
carried  on  further  in  the  intestine  by  the  pancreatic  juice  and 
the  secretions  of  the  intestine,  and  the  end-products  are  ab- 
sorbed as  salts  of  the  amino-acids.  An  important  point  which 
I  wish  to  emphasize  is  that  in  the  intestine  of  every  infant  there 
are  always  two  forces  working  against  each  other.  That  is,  the 
end-products  from  the  breaking  down  of  fat  and  sugar  are  acid 


INTRODUCTION   TO    FEEDING   IN   GENERAL  21 

in  reaction;  those  from  the  breaking  down  of  protein  are  alka- 
line in  reaction,  from  the  ammonia  which  is  formed.  The 
normal  reaction  of  a  child's  stool  is  slightly  alkaline,  slightly 
acid,  or  neutral,  and  if  there  is  too  great  acidity  or  too  great 
alkalinity,  trouble  results.  It  is  very  important  to  have  such  a 
balance  between  the  fat  and  sugar  and  the  protein  in  the  food 
as  not  to  have  too  great  acidity  or  too  great  alkalinity  in  the 
intestine. 

You  have  all  probably  heard  a  good  deal  of  discussion  about 
"calories."  What  is  a  calorie?  Of  course,  all  food  is  fuel. 
The  different  elements  of  food  have  different  fuel  value,  and  we 
measure  this  fuel  value  by  calories.  A  calorie  is  the  amount  of 
heat  that  is  necessary  to  raise  one  liter  of  water  one  degree  centi- 
grade. This  is  a  "large"  calorie,  which  is  the  one  we  use  in 
infant  feeding.  The  average  baby  needs  about  50  calories  per 
pound  of  body  weight  in  order  to  thrive.  The  different  food 
elements,  produce  different  amounts  of  these  calories.  Fat  pro- 
duces 9.3  calories  per  gram;  protein  and  sugar  each  produce 
4.1  calories  per  gram. 

That  covers  the  bare  essentials  of  the  theoretical  part  of  our 
subject,  and  although  it  may  sound  rather  complicated  and  not 
very  practical,  it  is  necessary  to  understand  the  scientific  ground- 
work upon  which  rests  the  practical  superstructure  of  our  ideas 
of  infant  feeding. 

BREAST  FEEDING 

In  regard  to  breast  feeding,  it  is  an  axiom  that  every  haby  should 
he  fed  upon  the  breast  if  possible.  Of  course,  there  are  a  good 
many  women  who  cannot  nurse  their  babies,  but  it  should  be 
insisted  upon  that  every  woman  who  is  able  should  nurse  her 
baby  through  the  first  year.  Breast  milk  produces  the  big, 
robust  babies,  and  babies  who  are  breast  fed  have  very  little 
chance  of  developing  the  gastro-intestinal  troubles  of  various 
sorts  which  bottle-fed  babies  are  so  likely  to  have,  especially  in 
the  summer.  Of  course,  in  some  cases  a  baby  must  be  weaned, 
but  these  cases  are  comparatively  few.  Persist  in  breast  feed- 
ing, and  do  not  take  the  baby  off  the  breast  merely  because  it  perhaps 
vomits  once  or  twice  or  does  not  gain  on  the  breast  milk.  If  a 
mother  has  not  enough  milk,  try  to  find  out  why.    Look  after 


22  INFANT  FEEDING   (BOSTON  METHODS) 

her  habits,  see  that  she  leads  a  reasonable,  quiet  life,  that  she  is 
not  worried  or  nervous  about  anything,  and  that  she  gets  a 
proper  diet. 

Another  thing:  sometimes  the  milk  is  late  in  coming  into  the 
breast.  Normally,  after  a  baby  is  born  it  comes  into  the  breast 
in  from  twenty-four  to  forty-eight  hours.  Sometimes  it  is 
delayed  for  four  or  five  days.  However,  don't  take  the  baby  off 
the  breast  because  the  milk  is  late  in  coming. 

How  is  a  new-born  baby  to  be  fed?  It  may  be  put  to  the 
breast  six  hours  after  birth.  This  may  not  furnish  much  nour- 
ishment, but  it  teaches  the  baby  to  suck,  and  it  stimulates  the 
breast  to  produce  milk.  For  the  first  twenty-four  hours  the 
'baby  should  be  nuj"sed  every  six  hours;  for  the  next  day,  every 
four  hours;  for  the  first  few  weeks  after  that,  every  two  hours. 

There  is  a  great  deal  of  discussion  in  all  the  pediatric  centers 
about  the  intervals  between  nursings,  but  I  really  think  most  of 
the  intervals — that  is,  two,  two  and  one-half,  three,  or  four- 
hour  intervals  are  reasonable.  Most  normal  babies  get  along 
well  on  any  of  those  intervals.  Personally,  I  think  it  is  best  to 
have  a  normal  baby  nursed  every  two  hours  during  the  first 
month;  for  the  next  three  months  every  two  and  one-half  hours; 
after  this,  every  three  hours.  It  is  a  good  thing  to  have  the 
baby  take  one  bottle  a  day.  This  gives  the  mother  more  time  to 
get  out  and  take  exercise  than  if  it  has  to  be  nursed  every  time. 

If  the  bowels  of  a  new-born  baby  have  not  moved  well  soon 
after  birth,  it  is  wise  to  give  a  small  dose  of  castor  oil,  because  the 
meconium  may  undergo  decomposition  and  make  the  baby  ill 
from  toxic  absorption,  so  it  is  important  to  clean  it  out  artificially 
if  it  has  not  cleaned  itself  out  naturally. 

It  is  important  to  have  the  baby  nursed  regularly,  and  not 
every  time  it  cries.  Have  this  distinctly  understood  by  the 
mother.  If  the  baby  is  asleep  at  the  time  of  nursing,  it  should 
be  waked.  It  is  better  to  give  the  baby  alternate  breasts  each 
feeding  rather  than  a  little  out  of  one  and  a  httle  out  of  the  other, 
for  if  one  is  used  for  each  nursing  it  will  be  emptied,  and  thus 
stimulated  to  the  production  of  more  milk. 

An  average  baby  will  empty  the  average  breast  in  about  fifteen 
minutes;  of  course  this  time  may  vary,  but  that  is  usually  the 
average.     A  baby  does  not  take  the  same  amount  of  milk  from  a 


INTRODUCTION   TO    FEEDING   IN   GENERAL  23 

breast  at  each  nursing,  and  at  some  feedings  it  will  take  only  one 
or  two  ounces,  at  others  six  or  seven.  This  is  not  very  impor- 
tant, however,  because  most  babies  get  the  same  amount  every 
twenty-four  hours.  If  little  is  taken  at  one  feeding,  it  will  be 
made  up  at  another.  The  twenty-four-hour  amount  is  the  im- 
portant thing  to  consider.  Sometimes  it  is  important  to  know 
if  a  baby  is  getting  enough  milk  in  a  day,  and  the  best  way  to 
learn  this  is  to  weigh  the  child  before  and  after  each  nursing. 
Take  the  difference  between  the  weights  before  and  after  nurs- 
ing, add  them  all  together,  and  the  result  will  be  the  number  of 
ounces  the  baby  is  getting  in  a  day,  as  an  ounce  of  milk  weighs 
about  an  ounce. 

It  is  true  that  every  baby  should  be  fed  on  the  breast,  but  it  is 
also  true  that  there  is  abnormal  breast  milk — bad  breast  milk. 
There  are  four  kinds  of  bad  breast  milk.  The  first  kind  is  too 
rich — it  has  too  much  of  every  food  element.  This  type  of 
milk  is  found  in  certain  women  of  the  upper  classes  usually,  who 
eat  too  much  rich  food  and  who  do  not  take  enough  exercise. 
The  second  type  is  one  in  which  the  fat  and  sugar  are  low  and 
the  protein  high.  This  sort  of  milk  is  seen  in  the  poorer  classes 
of  women  who  do  not  get  enough  to  eat  and  who  have  to  work 
too  hard.  The  third  type  of  milk  is  one  in  which  the  fat  and 
sugar  are  very  low  and  the  protein  very  high.  This  type  of 
milk  is  usually  found  in  excessively  neurotic  women.  The 
fourth  type  of  milk  is  that  in  which,  by  repeated  chemical 
analyses,  it  is  found  that  every  one  of  the  elements  is  in  perfect 
proportion;  but  which,  for  some  reason  or  other,  the  baby  can- 
not take.  I  do  not  know  the  cause,  but  it  is  unquestionably  true 
that  in  the  milk  of  some  nursing  women  a  toxic  substance  is 
secreted,  and  this  upsets  the  baby.  In  one  case  I  analyzed  the 
milk  three  times  and  found  it  perfectly  normal,  but  the  baby 
could  not  take  it  at  all  and  had  to  be  weaned.  Of  course,  in 
considering  this  type  of  milk  it  must  be  taken  into  account  that 
the  trouble  may  be  in  the  baby  and  not  in  the  milk,  and  that  the 
milk  might  be  perfectly  suitable  for  some  other  baby. 

This  type  of  milk  is  not  common,  but  it  is  certainly  seen  some- 
times. It  ought  not  to  be  assumed,  however,  that  a  milk  is  of 
this  sort  until  the  nursing  mother  has  been  given  a  very  thorough 
trial  and  until  the  milk  has  been  analyzed,  if  possible.     Never 


24  INFANT   FEEDING    (BOSTON  METHODS) 

give  up  nursing  until  every  means  has  been  tried  of  modifying 
the  mother's  milk  and  making  it  better. 

How  may  the  chemical  composition  of  a  nursing  mother's 
milk  be  modified? 

When  a  woman  has  too  rich  milk,  the  important  things  are  to 
take  her  outdoors, — make  her  exercise, — keep  her  bowels  open, 
cut  down  on  her  diet,  and  make  her  drink  plenty  of  water.  In 
the  other  type,  where  the  milk  is  too  thin,  ease  up  the  woman's 
home  hfe,  have  her  arrange  to  get  some  one  to  do  part  of  her 
work,  and  have  her  eat  more,  especially  fatty  and  starchy  food. 
If  the  quantity  of  milk,  on  the  other  hand,  is  too  little,  have  her 
drink  plenty  of  fluid.  I  have  many  of  my  nursing  mothers  take 
corn-meal  gruel  at  night  before  going  to  bed.  It  is  of  no  use, 
however,  to  give  more  than  three  or  four  pints  of  fluid  a  day; 
anything  over  this  does  more  harm  than  good.  Another  thing, 
and  probably  the  most  important  of  all :  use  the  breast.  There 
is  nothing  which  will  stimulate  milk  production  so  well  as  a  com- 
plete emptying  at  each  nursing.  If  the  baby  is  weak  and  small 
and  does  not  empty  the  breast,  pump  it  out.  There  is  no  drv^ 
with  which  I  am  familiar  that  will  increase  milk  secretion. 

As  to  the  diet  of  the  mother :  I  think  the  best  thing  to  tell  a 
nursing  mother  in  average  circumstances  is  to  eat  exactly  what 
she  would  if  she  had  no  baby  at  all,  provided  she  is  taking  a 
reasonable  diet.  Undoubtedly  there  are  certain  things  which 
may  be  eaten  by  a  nursing  mother  that  will  influence  the  milk 
and  upset  the  baby.  Cabbage,  strawberries,  and  certain  other 
fruits  and  vegetables  sometimes  do  this.  Babies  generally  get 
on  well,  however,  if  the  mother  is  healthy  and  eats  an  average 
ordinary  diet. 

How  much  should  a  normal  breast-fed  baby  gam?  It  should 
be  weighed  every  week,  so  that  its  progress  can  be  followed, 
and  the  food  corrected,  if  necessary.  The  normal  breast-fed 
baby  should  gain  six  to  eight  ounces  a  week  for  the  first  five 
months  of  its  Ufe.  For  the  rest  of  the  first  year  it  should  gain 
four  to  six  ounces  a  week.  If  it  does  not  gain  as  much  as  this, 
there  is  something  wrong.  The  weight  of  a  baby  is  one  of  the 
best  indices  we  have  to  determine  whether  or  not  it  is  thriving, 
and  the  weighing  of  babies  is  neglected  in  altogether  too  many 
cases. 


INTRODUCTION   TO   FEEDING   IN   GENERAL  25 

The  breast-fed  baby  usually  has  three  or  four  rather  loose, 
golden-yellow,  sour-smelling  movements  a  day.  Those  fed  on 
cow's  milk  usually  do  not  have  so  many. 

Certain  babies  may  have  more  than  others  and  the  stools  may 
be  green  in  color  and  smell  bad.  The  baby  may  vomit  a  little. 
But  if  it  is  getting  on  well  in  every  other  way  and  is  gaining 
weight,  it  is  best  not  to  pay  too  much  attention  to  this. 

Let  us  take  up  the  abnormal  breast-fed  baby,  the  baby  who  is 
not  gaining  on  the  breast,  who  has  a  good  deal  of  colic,  who  does 
not  sleep  at  night,  who  vomits  often,  who  has  bad  movements; 
and  the  thin,  poorly  nourished,  breast-fed  baby  who  does  not 
get  enough  to  eat.  These  troubles  may  be  due  to  a  number  of 
causes.  If  a  baby  does  not  gain,  but  has  no  symptoms  of  in- 
digestion, the  milk  may  not  be  rich  enough  or  there  may  not  be 
enough  of  it.  In  cases  like  this  substitute  feedings  should  be 
given  after  a  trial  has  been  made  to  increase  the  amount  and 
richness  of  the  milk.  Modified  cow's  milk  can  be  given  after 
each  breast  feeding,  or  it  can  be  substituted  in  alternate  feedings 
with  the  breast.  It  is  a  little  better  to  give  it  after  each  breast 
feeding,  because  cow's  milk  is  better  taken  care  of  in  the  stomach 
when  it  is  mixed  with  human  milk. 

When  a  baby  has  colic,  when  it  is  fussy  most  of  the  time  and 
does  not  gain,  the  milk  is  probably  too  rich,  or  too  much  is  taken 
at  a  feeding.  It  may  contain  too  much  fat  or  protein.  The 
sugar  in  human  milk  gives  very  little  trouble.  The  symptoms 
of  fat  indigestion  are  vomiting  of  creamy,  thick,  sour-smelling 
material,  diarrhea,  failure  to  gain,  and  fussiness.  The  symp- 
toms of  protein  indigestion  are  the  same,  except  that  the  vomi- 
tus  is  not  quite  so  thick  and  creamy. 

Treat  these  conditions  by  treating  the  mother  in  the  first 
place,  by  taking  her  outdoors,  having  her  walk,  take  exercise, 
and  by  getting  her  to  drink  plenty  of  water.  In  the  second 
place,  keep  the  baby  quiet  after  each  nursing.  Do  not  let  the 
mother  shake  it  up  and  down,  as  so  many  do.  Also,  it  is  a  very 
good  idea  to  give  a  tablespoonful  of  boiled  water  to  dilute  the 
milk.  Again,  it  is  well  not  to  let  the  baby  nurse  too  long.  It 
may  be  getting  too  much  milk.  Sometimes  if  the  intervals 
between  nursings  are  increased,  it  will  help  these  cases. 

As  to  colic,  the  treatment  is  to  prevent  it,  if  possible,  by  regu- 


26  INFANT   FEEDING    (BOSTON   METHODS) 

lating  the  feeding.  The  best  thing  to  do  during  the  attacks  is  to 
give  a  suds  enema,  hot  appHcations  to  the  abdomen,  half  a  soda- 
mint  tablet,  a  few  drops  of  gin  or  aromatic  spirits  of  ammonia, 
or  peppermint  water. 

A  very  common  cause  of  disturbance  in  breast-fed  babies  is 
irregular  feeding  intervals.  Many  mothers  nurse  their  babies 
every  time  they  cry,  and  thus  they  are  fed  sometimes  every 
half-hour,  sometimes  every  three  hours.  Such  feeding  as  this 
is  bound  to  cause  trouble;  the  usual  symptoms  are  failure  to 
gain,  fussiness  and  sleeplessness,  colic,  vomiting,  and  the  passage 
of  an  increased  number  of  loose  stools,  which  may  be  green. 
Oftentimes  it  is  surprising  to  see  how  much  may  be  done  for 
babies  of  this  sort  simply  by  regulating  the  nursing  periods. 

Many  babies  have  the  same  sort  of  symptoms  because  the 
mother  is  upset  or  worried  about  something  or  because  the 
household  is  in  confusion.  A  nervous  mother  and  a  nervous 
household  make  a  nervous  and  unstable  baby,  and  many  babies 
may  have  severe  symptoms  of  indigestion  and  may  fail  to  gain 
in  weight  for  a  number  of  weeks  until  calm  and  quiet  conditions 
are  restored  in  the  household.  The  mother  should  be  in  a  quiet 
room,  without  any  noise  or  confusion  around  if  possible,  when 
she  is  nursing  her  baby;  and  after  the  nursing,  it  should  be  put 
into  its  bed  and  left  alone  for  half  an  hour.  Some  babies  may 
swallow  a  good  deal  of  air  when  they  nurse,  and  with  these 
babies  it  is  a  good  idea  for  the  mother  to  interrupt  the  nursing 
every  two  or  three  minutes  and  hold  the  baby  up  against  her 
shoulder,  slapping  its  back  gently,  to  give  it  a  chance  to  get  rid 
of  this  swallowed  air,  which  may  cause  colic. 

There  are  certain  indications  for  weaning.  Many  mothers 
have  the  idea  that  if  menstruation  starts  the  baby  should 
be  weaned.  This  is  not  so.  Sometimes  menstruation  in  the 
mother  does  upset  the  baby  temporarily,  but  it  will  probably  be 
right  again  in  a  day  or  two.  If  a  nursing  mother  becomes 
pregnant,  however,  the  baby  should  be  weaned  immediately 
in  most  cases.  Women  with  any  wasting  disease,  such  as  tu- 
berculosis, cancer,  or  chronic  nephritis,  in  most  cases  should  not 
be  allowed  to  nurse  their  babies.  It  is  also  best  to  wean  the 
baby  if  the  mother  develops  any  severe  acute  illness,  such  as 
typhoid  fever  or  pneumonia.     If  the  mother  has  a  "cold"  or 


INTRODUCTION   TO   FEEDING   IN   GENERAL  27 

slight  tonsillitis,  it  is  best  to  discontinue  nursing  for  a  day  or 
two,  or  perhaps  in  some  cases  not  to  discontinue  it  entirely,  but 
to  substitute  bottle  feedings  for  half  of  the  breast  feedings. 

If  a  mother  cannot  nurse  her  baby,  it  is  often  a  very  great 
advantage  to  get  a  wet-nurse.  What  are  the  qualifications  of  a 
wet-nurse?  In  the  first  place,  how  is  the  wet-nurse's  own 
baby?  If  it  is  doing  well,  the  chances  are  that  the  other  baby 
will  do  well.  No  one  should  be  taken  whose  own  baby  is  over 
eight  or  nine  months  old,  because  after  this  period  the  milk 
becomes  thin  and  poor  in  quaUty.  Every  nurse  should  have 
a  thorough  physical  examination  to  exclude  tuberculosis  and 
syphilis.  A  Wassermann  should  be  done  on  the  blood  of  every 
wet-nurse  if  possible. 

ARTIFICIAL  FEEDING 

In  artificial  feeding,  what  kind  of  milk  is  to  be  used?  There 
is  another  axiom  in  pediatrics,  and  that  is  that  no  milk  is  too 
goodjor  ahahy.  Get  the  very  best  milk  possible.  Get  it  from  a 
good  dairy,  from  a  farmer  who  takes  care  of  his  barns  and  his 
cattle  and  who  is  interested  in  producing  good  milk.  There  is 
nothing  that  causes  so  many  babies  to  die  as  unclean  milk. 
Milk  is  really  one  of  the  dirtiest  things  in  the  world,  because  of 
the  conditions  under  which  it  is  produced  and  the  ease  with 
which  bacteria  grow  in  it. 

A  handful  of  dirt  may  be  thrown  into  a  bottle  of  milk  and  it 
cannot  be  seen.  What  looks  like  clean  milk  may  be  centrifuged 
and  a  large  amount  of  dirt  may  be  found  as  a  sediment.  An 
Ayrshire,  Holstein,  or  plain  ordinary  "cow"  is  usually  the  best 
cow  from  which  to  procure  the  baby's  milk.  Many  of  the  laity 
prefer  a  Jersey,  but  Jersey  milk  is  too  rich.  The  fat  may  often 
run  up  to  6  or  7  percent,  and  the  baby  may  get  into  a  great  deal 
of  trouble  on  account  of  this  high  fat  percentage. 

A  baby  may  be  fed  on  raw  milk  or  on  pasteurized  or  sterilized 
milk.  I  have  no  hesitation  in  saying  that  every  milk  fed  vO  a 
baby  should  be  pasteurized  or  sterilized,  especially  in  a  warm 
climate  like  this,  unless  it  is  what  is  called  "certified"  milk. 
Certified  milk  composes  less  than  1  percent  of  the  milk  supply 
of  great  cities.  It  is  produced  under  the  greatest  precautions. 
The  cow  is  washed  off  before  milking,  the  milkers  wear  white 


28  INFANT  FEEDING   (BOSTON  METHODS) 

gloves,  the  barns  are  sanitary,  and  every  possible  precaution  is 
taken  to  produce  good  milk.  But,  of  course,  such  milk  is  only 
a  very  small  proportion  of  the  milk  supply,  and  the  milk  that 
babies  get  should  in  practically  all  cases  be  sterilized  or  pas- 
teurized. Insist  upon  this.  I  do  not  know  much  about  the 
milk  supply  of  North  Carolina,  but  I  think  it  would  be  a  great 
deal  better  if  it  were  pasteurized  or  sterilized  before  being  fed 
to  babies,  and  I  hope  that  you  will  all  feed  all  your  babies  on 
pasteurized  or  sterilized  milk  this  summer. 

There  has  been  a  great  deal  of  objection  to  pasteurized  milk 
because  some  people  think  it  is  harder  to  digest.  This  is  not  so. 
Some  people  say  that  it  tends  to  constipate  the  baby.  But 
what  if  it  does?  A  slight  amount  of  constipation  is  better  than 
dysentery.  Some  people  say,  too,  that  it  is  too  much  work  to 
pasteurize  milk,  but  it  is  really  not  very  much  more  trouble. 
The  greatest  objection  is  that  pasteurized  and,  more  especially, 
sterilized  milk  may  produce  scurvy;  but  this  is  not  much  of  an 
objection.  Scurvy  can  be  cured  in  a  few  days  by  the  use  of 
orange-juice,  and  it  can  be  prevented  by  the  use  of  two  table- 
spoonfuls  of  orange-juice  a  day.  In  Boston  nearly  all  milk  fed 
to  babies  is  pasteurized  except  the  certified  milk.  The  latter 
costs  twenty  cents  a  quart,  and  is  therefore  out  of  the  question 
for  most  people.  Pasteurization  is  not  an  excuse  for  bad  milk. 
Milk,  whether  pasteurized  or  not,  should  be  good  milk  to  start 
with,  if  possible. 

What  is  the  difference  between  pasteurization  and  steriliza- 
tion? They  are  two  different  processes.  Pasteurization  con- 
sists of  heating  milk  to  145''  F.  and  keeping  it  at  that  tempera- 
ture for  thirty  minutes.  This  does  not  kill  the  ferments  in  the 
milk,  but  it  does  kill  almost  all  the  bacteria  except  the  spore- 
bearing  bacteria,  of  which  the  gas  bacillus  is  the  most  important. 
Sterilizing  milk,  on  the  other  hand,  consists  in  boiling  it,  which 
kills  all  the  bacteria. 

A  great  many  devices  for  pasteurizing  milk  have  been  put  on 
the  market,  which  are  convenient,  but  not  at  all  necessary. 
Milk  may  be  very  efficiently  pasteurized  with  a  simple  home- 
made apparatus  as  follows: 

Put  the  milk  bottles  and  some  warm  water  into  an  ordinary 
tin  pail  and  heat  until  the  temperature  of  the  water  is  145°  F. 


INTRODUCTION   TO    FEEDING   IN   GENERAL  29 

Then  take  the  pail  off  the  stove,  put  a  small  doubled-up  blanket 
over  it,  and  let  it  stand  for  half  an  hour.  Pour  off  the  hot 
water  and  fill  the  pail  with  cold  water  in  order  to  cool  the  milk 
as  quickly  as  possible,  as  spores  develop  very  readily  in  luke- 
warm milk. 

Sterilization  consists  in  boiling  the  milk  for  four  or  five  min- 
utes. Whether  or  not  sterilization  or  pasteurization  should  be 
employed  depends  largely  upon  the  sort  of  people  one  is  dealing 
with.  If  they  will  take  the  trouble  to  do  it,  pasteurization  is 
better. 

If  a  baby  is  fed  on  pasteurized  or  sterilized  milk,  it  should  be 
given  orange-juice  as  a  prophylactic  against  scurvy.  The  best 
way  to  give  this  is  in  two  doses,  a  tablespoonful  morning  and 
night.     It  is  best  given  about  an  hour  before  feeding. 

I  have  mentioned  a  number  of  times  the  "modification"  of 
milk.  Just  how  is  milk  to  be  modified?  The  modification  of 
milk  consists  in  adding  water  or  other  substances  to  cow's  milk 
to  change  it  to  suit  the  digestion  of  the  individual  baby  that  is 
being  treated.  What  is  of  the  utmost  importan.ce  to  remember 
is  to  fit  the  milk  to  the  individual  baby.  There  are  no  definite 
rules  or  laws  that  can  be  laid  down,  because  babies  vary  so  much 
in  what  they  will  take  and  in  their  digestive  capacities,  but  there 
are  certain  broad  principles  which  may  be  followed  in  a  general 
way. 

There  is  no  question  but  that  the  average  practitioner  feels 
helpless  when  it  is  a  question  of  milk  modification,  and  the 
reason  for  it  is  this.  Every  man  who  writes  a  text-book  of 
pediatrics  has  a  different  method  of  milk  modification,  and 
usually  gives  complicated  formulae  and  long  tables  which  he 
himself  understands  perfectly,  but  which  are  usually  hopeless 
for  the  average  practitioner  to  carry  in  his  mind.  Thus  great 
confusion  has  arisen:  there  are  so  many  different  methods.  I 
feel  very  strongly  that  tables  showing  how  much  milk,  water, 
etc.,  should  be  mixed  to  feed  a  baby  of  a  given  age  should  be  used 
as  little  as  possible.  In  the  methods  I  am  going  to  teach  you 
one  remembers  about  what  percentages  should  be  fed  to  a  baby 
of  a  given  age ;  then  he  figures  by  the  aid  of  certain  data  which 
can  be  easily  carried  in  the  head  the  amounts  of  milk,  cream, 
water,  and  sugar  to  use  to  make  up  the  desired  formula.  Thus 
multitudinous  formula  and  tables  are  largely  done  away  with. 


30  INFANT   FEEDING    (BOSTON  METHODS) 

I  am  going  to  teach  you  two  slightly  different  methods  of  modi- 
fying milk,  which  I  am  sure  you  will  find  very  simple  of  applica- 
tion: the  "gravity"  cream  and  skimmed-milk  method  and  the 
"whole"  milk  dilution  method. 

Top  or  "gravity"  cream  is  all  the  cream  that  is  visible  in  a 
quart  of  milk  in  an  ordinary  milk  bottle  after  the  milk  has  stood 
for  about  six  hours.  It  is  usually  about  six  ounces  of  cream, 
and  the  composition  is  about  16  percent  fat,  4.5  percent  sugar, 
3.2  percent  protein.  There  are  various  methods  of  taking  off 
this  cream,  which  we  will  discuss  later.  What  is  left  behind, 
after  taking  it  off,  is  skimmed  milk,  which  consists  of  no  fat, 
4.5  percent  sugar,  3.2  percent  protein.  These  figures  are  not 
exact,  but  they  are  what  we  use  in  calculating  our  milks.  The 
skimmed  milk,  cream,  water,  and  sugar  are  mixed  in  such  pro- 
portions as  to  secure  the  percentages  of  food  elements  that  are 
desired  to  feed  the  baby. 

The  other  method  of  modifying  milk  consists  in  diluting  whole 
milk  with  water  and  adding  milk-sugar  to  secure  the  desired 
percentages.  This  method  of  whole  milk  dilution  has  one  dis- 
advantage, which  is  that  if  the  milk  is  diluted  enough  to  reduce 
the  protein  percentage  to  the  amount  which  the  baby  can  digest 
the  fat  is  reduced  too  much,  and  the  food  does  not  contain  a 
sufficient  number  of  calories  for  the  baby's  nutrition.  How- 
ever, a  great  many  babies  do  very  well  on  this  method,  but 
others  do  not.  Most  normal  babies  will  do  perfectly  well  on 
whole  milk  and  water  dilutions,  but  not  many  difficult  feeding 
cases  can  be  fed  by  this  method.  In  each  case  the  circumstances 
and  the  people  have  to  he  sized  up.  Some  people  will  not  take  the 
trouble  to  take  off  the  cream  and  to  go  through  the  various  steps 
in  a  cream  and  skimmed-milk  modification.  The  other  method 
is  easier,  and  if  I  am  dealing  with  ignorant  people  I  tell  them  to 
use  this  method  of  whole  milk  dilution. 

In  feeding  a  baby,  six  things  have  to  be  decided : 

1.  What  percentages  of  the  food  elements  is  it  to  take? 

2.  How  much  food  is  to  be  given  in  the  twenty-four  hours? 

3.  How  much  food  at  each  feeding? 

4.  How  often  are  the  feedings? 

5.  What  method  of  milk  modification  is  to  be  used? 

6.  How  many  calories  is  the  baby  getting?  Does  the  food 
prescribed  furnish  enough  calories  to  make  it  gain  weight? 


LECTURE  n 
THE  MODIFICATION  OF  MILK 

As  an  introduction  to  the  lecture  today,  which  deals  with  the 
modification  of  milk  and  the  calculation  of  percentages  and 
calories,  I  can  do  no  better  than  to  quote  some  words  of  Dr. 
John  Lovett  Morse,  of  Boston: 

"In  approaching  the  subject  of  artificial  feeding,  it  must  be  remembered 
that  there  are  only  a  few  food  elements.  A  baby's  food  may  contain  all 
these  elements;  it  must  contain  some  of  them,  it  cannot  contain  any  other 
elements.  These  food  elements  are  fat,  carbohydrate,  protein,  and  salts. 
It  must  also  be  remembered  that  a  baby,  in  order  to  thrive  and  gain,  must 
have  a  sufficient  amount  of  food.  The  amount  of  food,  in  considering  its 
fuel  value,  is  not  calculated,  however,  in  ounces  or  pints  of  food,  but  in  food 
values  or  calories.  A  baby  must  receive  a  sufficient  number  of  calories  in 
proportion  to  its  body  weight,  otherwise  it  cannot  gain.  It  is  not  sufficient, 
however,  for  a  food  to  contain  a  sufficient  number  of  calories;  it  must  also 
contain  a  sufficient  amount  of  protein  to  cover  the  nitrogenous  needs  of  the 
baby.  It  must  further  be  remembered  that  a  food  may  contain  enough 
calories  and  enough  protein  to  cover  the  caloric  and  protein  needs  of  the 
baby,  and  yet  not  be  a  suitable  food  for  any  baby,  or  if  suitable  for  one  baby, 
not  for  another. 

"It  is  absolutely  necessary  to  fit  the  food  to  the  digestive  capacity  of  the 
individual  infant.  These  fundamental  principles  must  be  always  borne  in 
mind  in  feeding  babies  artificially.  If  they  are  forgotten,  the  result  is 
likely  to  be  failure  rather  than  success." 

You  will  remember  that  I  said  at  our  last  lecture  that  there 
were  two  methods  of  milk  modification  we  were  going  to  con- 
sider: 

1.  The  "gravity"  cream  and  skimmed-milk  method. 

2.  The  "whole"  milk  dilution  method. 

I  also  said  that  there  is  more  trouble  to  the  first  method,  but 
that  it  is  likely  to  give  better  results  in  difficult  feeding  cases, 
and  that  the  second  method  is  a  good  deal  simpler  to  use  and 
more  applicable  for  most  patients,  especially  when  they  are  not 
intelligent  enough  to  carry  out  the  first  method. 

Gentlemen,  I  know  that  the  figures  and  formulae  we  are  going 

31 


.32  INFANT  FEEDING    (BOSTON  METHODS) 

to  talk  about  may  seem  complicated  to  you,  but  I  want  to  say 
now,  before  we  go  any  further,  that  infant  feeding  is  fussy,  and 
that  if  a  man  wishes  to  have  any  success  whatever  with  it  he 
must  be  willing  to  go  into  considerable  detail  and  take  as  miich 
pains  with  his  feeding  cases  as  he  would  take  with  the  most 
difficult  surgical  or  obstetrical  case. 

First,  let  us  consider  the  gravity  cream  and  skimmed- 
milk  method.  Gravity  cream  is  all  the  cream  that  is  visible 
on  a  quart  bottle  of  milk  that  has  stood  about  six  hours. 
This  amounts  usually,  in  an  average  milk,  to  about  6  ounces. 
Skimmed  milk  is  wh^t  is  left  behind  after  the  gravity  cream  has 
been  removed. 

Gravity  cream  has  the  following  composition: 

Fat 16.0  percent 

Sugar 4.5 

Protein 3.2       " 

Skimmed  milk  has  the  following  composition: 

Fat 0.0  percent 

Sugar 4.5       " 

Protein 3.2 

These  percentages  are  not  absolutely  correct,  but  are  the  ones 
we  use  in  our  calculations,  and  for  practical  purposes  are  near 
enough. 

I  am  not  going  to  speak  of  the  way  in  which  to  take  care  of  the 
utensils  used  in  milk  modification, — you  can  get  this  from  any 
text-book, — but  will  merely  say  that  the  thing  of  greatest  im- 
portance is  to  have  all  utensils  as  clean  as  possible.  There  are  a 
number  of  ways  of  separating  the  cream  from  the  skimmed 
milk,  the  most  practical  of  which  are  pouring  and  dipping. 
Pouring  is  the  simpler,  but  not  very  accurate,  and  if  one  is  deal- 
ing with  a  family  who  will  take  the  trouble,  it  is  best  to  have 
them  remove  the  cream  with  a  small  dipper.  The  dipper  de- 
vised by  Dr.  Chapin,  of  New  York,  and  known  as  the  "Chapin 
dipper,"  is  the  best,  and  can  be  obtained  at  most  drug-stores. 

Now  suppose  we  want  to  prepare  a  certain  formula,  let  us  say: 

Fat 3  percent 

Sugar 6       " 

Protein 2       " 


THE  MODIFICATION   OF  MILK  33i 

The  amount  to  be  32  ounces,  and  the  lime-water  in  the  mixture 
to  be  25  percent  of  the  skimmed  milk  and  cream  used:  how 
much  cream  do  we  need?  We  want  3  percent  of  fat — all  the 
fat  is  coming  from  the  cream;  the  fat  content  of  our  cream 
is  16  percent,  therefore  A  of  our  mixture  will  be  cream:  A  of 
32  =  6.  Therefore  6  ounces  cream  will  go  into  our  mixture. 
How  much  protein  did  we  put  in  with  the  cream?  Cream  con- 
tains 3.2  percent  protein,  so  if  we  had  made  up  our  complete 
mixture  of  32  ounces  with  cream  alone,  we  would  have  put  in 
3.2  percent  protein.  But  we  are  putting  into  our  32-ounce 
mixture  only  6  ounces  of  cream.  Therefore  we  have  put  in — 
/j  of  3.2  percent  =  0.6  percent  protein. 

But  we  want  2  percent  of  protein  in  our  mixture.  We  want 
1.4  percent  more  protein.  This  is  to  come  from  the  skimmed 
milk.     We  want — 

1 4 
-^-^  of  32  =  14  ounces. 

Then  we  put  into  our  mixture  14  ounces  of  skimmed  milk, 
giving  us  so  far  20  ounces  of  cream  and  milk  in  all.  How  much 
sugar  did  we  put  in  with  this  cream  and  skimmed  milk?  If 
we  had  put  into  our  32-ounce  mixture  32  ounces  of  cream  and 
skimmed  milk,  we  would  have  put  in  4.5  percent  of  sugar;  but 
we  put  in  only  20  ounces, 

So-^  of  4.5  =  3  percent  sugar. 

We  need  3  percent  more  sugar,  as  we  wanted  6  percent  of 
sugar  in  our  formula.  The  deficit  is  made  up  with  dry  milk- 
sugar.  What  we  want  is  Tfir  (3  percent)  of  32  ounces.  This 
equals  1  ounce.  A  rounded  tablespoon  of  milk-sugar  equals 
}/2  ounce.  Then  we  put  in  two  rounded  tablespoons  of  milk- 
sugar.  We  wanted  our  lime-water  to  be  25  percent  of  the  milk 
and  cream  used. 

25  percent  of  20  =  5. 

Then  we  need  5  ounces  of  lime-water. 

Gravity  cream 6  ounces 

Skimmed  milk 14       " 

Lime-water 5       " 

Water 7       " 

Milk-sugar 2  rounded    table- 
spoonfuls 
3 


34  INFANT   FEEDING    (BOSTON   METHODS) 

I  know  that  all  this  seems  very  complex,  but  you  will  not  have 
to  figure  out  all  your  modifications  this  way,  as  I  can  show  you 
some  short  cuts  which  will  simplify  matters  greatly.  It  is  very 
important,  however,  to  know  how  to  use  this  long  method  of 
calculation,  even  if  you  do  not  use  it  much.  The  calculation  is 
just  the  same  for  any  formula,  and  any  desired  formula  may  be 
calculated  by  using  this  one  as  a  model.  The  advantage  of 
knowing  this  method  of  calculation  is  that  no  tables  whatever 
are  necessary :  all  that  is  necessary  is  to  remember  the  percent- 
age composition  of  the  milk  and  cream  and  the  various  steps 
used  in  the  calculation,  and  when  it  is  once  learned,  it  is  not  for- 
gotten. /  wish  to  emphasize  particularly  that  not  one  of  you  can 
learn  to  figure  formulas  by  hearing  me  talk  about  it:  you  must 
give  the  miitter  a  little  thought  yourselves  and  take  a  pencil  and  paper 
and  figure  a  few.  If  you  are  willing  to  give  the  matter  an  hour 
of  your  time  some  day,  I  am  sure  that  you  can  all  learn  to  calcu- 
late these  formulae  very  quickly  and  readily,  and  that  you  will 
find  this  of  great  value  in  your  practice.  A  great  many  practi- 
tioners have  objected  to  percentage  feeding  on  the  ground  that 
the  calculation  of  the  formulae  is  too  complicated.  It  is  more  a 
question  of  laziness  than  anji;hing  else;  any  man  can  learn 
these  methods  if  he  is  wilUng  to  take  a  Uttle  trouble,  but  he  cer- 
tainly never  can  learn  them  by  reading  this  over  superficially  or 
by  hearing  some  one  else  talk  about  them;  he  must  do  a  little 
thinking  for  himself.  It  is  often  of  importance  to  calculate 
backward;  that  is,  if  it  is  known  that  a  certain  number  of 
ounces  each  of  skimmed  milk,  gravity  cream,  and  milk-sugar 
are  being  used,  how  can  it  be  determined  what  percentages  are 
being  obtained?    Let  us  say  we  are  using  this  formula: 

Gravity  cream 8  ounces 

Skimmed  milk 20       " 

Water 20       " 

Milk-sugar 4  tablespoons 

Total  mixture  equals  48  ounces. 


Then: 


^V  of  16.0  =  2.6  percent  fat 
If  of    3.2  =  1.8  percent  protein 

II  of    4.5  =  2.8  percent  sugar,  went  in  with  the  skimmed 
milk  and  cream 


THE   MODIFICATION   OF  MILK  35 

Four  rounded  tablespoons  (2  ounces)  of  sugar  equal  about  4.00 
Then  we  have, 

Fat,  2.60;  sugar,  6.8;  protein,  1.8. 

Short  Method. — The  method  of  calculation  which  we  have 
been  discussing  is  of  value  because  when  it  is  once  learned  no 
tables  are  necessary.  But  it  is  rather  long;  it  is  a  good  deal  of 
trouble  to  go  to  all  this  figuring  every  time  a  modification  is 
prescribed,  and  it  is  usually  not  necessary,  for  there  are  certain 
short  cuts  which  simplify  matters  greatly,  and  which  enable  one 
to  figure  formulae  much  more  quickly  than  is  possible  with  the 
"long  method."  There  are  two  simple  tables  which  must  be 
remembered  if  this  short  method  is  used,  but  these  are  not 
complicated  and  they  can  usually  be  carried  in  the  head.  I 
think  this  short  method  is  the  one  you  will  want  to  ttse  in  feeding 
your  babies,  rather  than  the  long  one.     It  is  as  follows: 

In  a  16-ounce  mixture  the  number  of  ounces  of  16  percent 
(gravity)  cream  that  is  needed  always  equals  the  fat  percentage 
desired,  and  the  number  of  ounces  of  skimmed  milk  and  cream 
needed  always  equals  five  times  the  percentage  of  protein  de- 
sired. Thus,  let  us  say  that  a  mixture  of  16  ounces  is  wanted, 
containing: 

Fat 3  percent 

Sugar 6       " 

Protein 1       " 

Then— 

3  ounces  of  gravity  cream  is  needed 
1.8  (protein  percent  desired)  X  5  =  9  ounces  skimmed 
milk  and  cream 

This  means  6  ounces  skimmed  milk,  for  9  —  3  =  6. 

We  have  put  9  ounces  of  skimmed  milk  and  cream  into  a  16- 
ounce  mixture :  how  much  sugar  have  we  put  in  with  this? 

YE  of  4.5  percent  of  sugar  =  about  2.5  percent  sugar. 

We  need  3.5  percent  more  sugar.  How  much  dry  milk-sugar 
are  we  going  to  need?  This  can  be  very  easily  calculated  from 
the  following  sugar  table,  or  it  can  be  figured  out  by  ounces,  as 
we  did  in  the  long  method. 


36  INFANT  FEEDING   (BOSTON  METHODS) 

Sugar  Table 
One  level  tablespoon  of  sugar  raises  the  sugar  percentage — 

2.40  p>ercent  in  a  16-ounce  mixture 
2.00  percent  in  a  20-ounce  mixture 
1.60  percent  in  a  24-ounce  mixture 
1.20  percent  in  a  32-ounce  mixture 
1.00  percent  in  a  40-ounce  mixture 

.95  percent  in  a  42-ounce  mixtiu"e 

.80  percent  in  a  48-ounce  mixture 

In  this  16-ounce  mixture  we  are  dealing  with  we  have  figured 
that  we  need  3.5  percent  more  sugar.  Then,  dividing  3.5  by 
2.4  to  get  the  number  of  tablespoons,  we  get  3. 5 -j- 2.4  =1.4,  or 
about  13^  level  tablespoons  of  sugar.  Water,  of  course,  is 
added  up  to  16  ounces. 

This  method  of  calculating  simplifies  the  whole  procedure  a 
great  deal,  as  you  can  easily  see.  The  sugar  table  is  easily 
remembered  after  it  has  been  used  a  number  of  times. 

In  a  16-ounce  mixture,  you  will  remember,  the  figure  to  mul- 
tiply the  desired  fat  percentage  by  to  secure  the  required  num- 
ber of  ounces  of  cream  is  1,  and  the  number  to  multiply  the 
protein  percentage  by  to  secure  the  number  of  ounces  of  milk 
and  cream  is  5.  There  are  similar  figures  for  different  mixtures, 
which  are  as  follows: 

20  ounces:  Fat  factor,  1.25  Protein  factor,    6.2 

24  ounces:  Fat  factor,  1.50  Protein  factor,    7.5 

32  ounces:  Fat  factor,  2.00  Protein  factor,  10.0 

40  oimces:  Fat  factor,  2.50  Protein  factor,  12.5 

42  oimces:  Fat  factor,  2.60  Protein  factor,  13.1 

48  oimces:  Fat  factor,  3.00  Protein  factor,  15.0 

You  will  see  that  it  is  a  great  deal  easier  to  figure  modifications 
by  this  table  than  to  calculate  them  by  the  "long  method" 
which  I  first  spoke  of,  and  if  a  little  card  is  carried  in  the  pocket 
with  the  different  fat  and  protein  factors  on  it,  it  is  a  simple 
matter  to  figure  any  modification  in  a  very  short  time.  The 
mixtures  most  frequently  used  are  16-,  32-,  and  48-ounce  mix- 
tures, and  it  is  very  easy  to  remember,  without  any  card,  that 
the  fat  factors  are  1,  2,  and  3  respectively,  for  these  mixtures, 
and  the  protein  factors  5,  10,  and  15. 

This  covers  the  gravity  cream  and  skimmed  milk  method  of 
milk  modification. 


THE  MODIFICATION   OF  MILK  37 

Now  let  us  turn  to  the  whole  milk  method;  that  is,  simple 
dilutions  of  whole  or  skimmed  milk  with  water  and  addition  of 
sugar.  This  is  the  method  which  is  best  to  use  with  people  who 
are  too  ignorant  to  handle  the  skimmed  milk  and  cream  method, 
and  most  normal  babies  will  get  along  fairly  well  with  it.  As  I 
have  said  before,  its  disadvantages  are  that  the  fat  in  the  milk  is 
usually  too  much  reduced,  and  it  is  impossible  to  secure  by  this 
method  certain  combinations  of  percentages  of  the  food  elements 
which  can  be  obtained  by  the  use  of  the  gravity  cream  and 
skimmed  milk  method,  which  might  be  needed  in  feeding  cer- 
tain abnormal  babies.  It  depends  a  great  deal  upon  what  com- 
bination of  percentages  is  desired  whether  the  gravity  cream  and 
skimmed  milk  or  the  whole  milk  dilution  method  should  be 
used,  and  it  is  simpler,  if  one  can  get  the  percentages  one  wants 
by  it,  to  use  the  latter  method. 

Also,  normal  babies  over  eight  or  nine  months  old  can  be  fed 
very  well  on  whole  milk  dilutions,  as  what  we  are  driving  at  at 
this  period  of  the  baby's  life  is  to  get  it  gradually  onto  whole 
milk — and  a  baby  of  this  age  needs  comparatively  little  diluent 
in  its  milk,  so  the  fat  is  not  reduced  too  much  by  dilution. 
These  are  some  of  the  considerations  which  should  be  taken  into 
account  in  the  choice  of  a  method. 

In  using  whole  milk  dilutions  it  is  best  not  to  say  to  oneself 
that  one  wants  certain  percentages  in  the  formula,  and  then  to 
calculate  it  out,  for  in  many  cases  one  will  have  picked  out  an 
impossible  combination  of  fat  and  protein  percentages.  One 
can,  of  course,  obtain  any  sugar  percentage  desired  (provided  it 
is  not  too  low),  whether  the  cream  and  skimmed  milk  or  the 
whole  milk  method  is  used.  In  using  whole  milk  dilutions 
either  one  of  two  procedures  may  be  employed : 

1.  Use  the  desired  amounts  of  milk,  water,  and  sugar,  and 
then  calculate  what  the  percentages  are,  so  that  the  modifica- 
tion can  be  checked  and  the  approximate  composition  of  the 
mixture  determined,  so  that  the  baby  does  not  get  too  strong 
or  too  weak  a  formula.  As  a  matter  of  fact,  after  a  person 
has  fed  babies  for  a  while  this  way,  he  knows  almost  auto- 
matically about  what  the  percentages  are  in  any  dilution,  and 
does  not  need  to  stop  and  calculate  them.  It  is  not  accurate  or 
at  all  advisable,  except  in  the  case  of  babies  who  are  nearly  on 


38       .  INFANT   FEEDING    (BOSTON  METHODS) 

whole  milk,  or  in  those  who  have  infectious  diarrhea,  and  who 
are  being  underfed  any  way,  to  simply  mix  milk,  water,  and 
sugar  and  pay  no  attention  to  the  percentages;  one  is  likely  to 
get  into  trouble  if  this  is  done,  and  the  percentages  should  al- 
ways be  figured  as  a  check  to  this  method  of  feeding.  Let  us 
say  that  a  baby  is  being  fed  on  whole  milk  and  water  dilution, 
and  one  wants  to  know  what  percentages  it  is  getting.  Say  it  is 
taking  a  48-ounce  mixture: 

Whole  milk 36  ounces 

Water 12      " 

Milk-sugar 4  level  table- 
spoons 

Then,  as  whole  milk  contains: 

Fat 4.0 

Sugar 4.5 

Protein 3.2 

If  of  4.0  =  3.0  percent  fat  in  the  mixture 
If  of  4.5  =  3.3  percent  sugar  in  the  mixture 
If  of  3.2  =  2.4  percent  protein  in  the  mixture 

A  level  tablespoonful  of  milk-sugar  added  to  a  48-ounce 
mixture  raises  the  sugar  percentage  0.8  percent.  Therefore 
the  sugar  percentage  in  this  mixture  has  been  raised  3.2  percent, 
which,  added  to  the  sugar  that  has  already  been  put  in  with  the 
milk  (3.3  percent),  gives  5.5  percent  sugar  in  the  mixture,  and 
the  baby  is  getting — 

Fat 3.0 

Sugar 5.5 

Protein 2.4 

The  same  method  is  used  in  figuring  any  whole  or  skimmed 
milk  and  water  dilution. 

2.  Another  way  that  one  can  use  whole  milk  dilutions  is  with 
the  aid  of  a  table,  which  is  perhaps  easier.  In  any  whole  milk 
and  water  mixture  if  fV  of  the  mixture  is  milk,  that  is,  5 
ounces  milk  in  a  16-ounce  mixture,  and  the  rest  water,  the  per- 
centages are: 

Fat 1.25 

Sugar 1.40 

Protein .   1.00 


THE  MODIFICATION  OF  MILK  39 

Similarly,  if  more  milk  is  added: 

j%  =  Fat  1.50  Sugar  1.70  Protein  1.20 

^  =  Fat  1.75  Sugar  2.00  Protein  1.40 

^%  =  Fat  2.00  Sugar  2.25  Protein  1.60 

t\  =  Fat  2.25  Sugar  2.50  Protein  1.80 

U  =  Fat  2.50  Sugar  2.80  Protein  2.00 

H  =  Fat  2.75  Sugar  3.00  Protein  2.20 

II  =  Fat  3.00  Sugar  3.30  Protein  2.40 

The  amount  of  sugar  necessary  to  add  can  be  determined  by 
referring  to  the  sugar  table  given  above,  which  I  will  repeat 
again  for  the  sake  of  clearness : 

One  level  tablespoonful  of  sugar  raises  the  sugar  percentage — 

2.40  in  a  16-ounce  mixture 
2.00  in  a  20-ounce  mixture 
1.60  in  a  24-ounce  mixture 
1.20  in  a  32-ounce  mixture 
1.00  in  a  40-ounce  mixture 

.95  in  a  42-ounce  mixture 

.80  in  a  48-ounce  mixture 

The  table  of  whole  milk  dilutions  is  calculated  on  the  basis  of 
sixteenths.  Of  course,  if  one  is  dealing  with  a  32-ounce  or  a 
48-ounce  mixture,  the  fraction  fV  or  yV,  etc.,  is  multiplied 
through  by  2  or  3,  as  the  case  may  be;  that  is,  fV  is  the  same  as 

10.  nr  i^ 
3  2   or   4  8. 

Proportionate  calculations  can  be  made  for  24-ounce  or  40- 
ounce  formulae,  that  is,  in  a  24-ounce  mixture  the  amount  of 
each  ingredient  would  be  f  times  what  it  would  be  for  a  16-ounce 
mixture,  or  in  a  40-ounce  mixture  it  would  be  f  what  it  would  be 
for  a  32-ounce  mixture.  Thus  we  can  accurately  figure  from 
this  table  16-,  24-,  32-,  40-,  and  48-ounce  mixtures,  which  are 
the  most  common  ones  used. 

So  much  for  the  calculation  of  percentages.  The  "whole 
milk"  method  is  considerably  simpler  to  use  than  the  gravity 
cream  and  skimmed-milk  method,  and  it  will  probably  be  the 
more  practical  one  for  you  gentlemen  to  use  most  of  the  time  in 
feeding  many  of  your  normal  babies. 

Now  for  the  calculation  of  the  calories.  There  may  be  very 
accurately  calculated  percentages  of  the  food  elements  in  the 
mixture,  but  if  the  baby  is  not  getting  enough  to  eat,  they  do  not 
do  him  much  good.     Most  babies  require  about  50  calories  per 


40  INFANT  FEEDING    (BOSTON  METHODS) 

pound  of  body  weight  in  order  to  thrive.  This  varies  a  good 
deal,  of  course,  in  different  babies.  If  a  baby  is  gaining  weight 
steadily  and  is  doing  well,  there  is  not  much  use  in  calculating 
the  calories  in  its  food.  It  is  self-evident  that  it  is  getting  enough 
to  eat  from  the  simple  fact  that  it  is  gaining  weight.  If  it  is 
not  gaining,  however,  or  if  the  weekly  gains  are  too  small,  it  is 
advisable  to  calculate  the  caloric  value  of  the  food,  and  it  can  be 
done  very  easily  by  the  following  simple  formula: 

(2F  +  P  +  S)  X  IM  Q  =  total  calories 

F  =  The  fat  percentage  of  the  food 

P  =  The  protein  percentage  of  the  food 

S  =  The  sugar  percentage  of  the  food 

Q  =  The  twenty-four-hour  quantity  of  the  food 

To  a  man  who  has  not  been  brought  up  in  the  method  the  use 
of  so  many  figures  and  calculations  may  seem  extremely  compli- 
cated ;  but,  as  I  have  said  before,  the  feeding  of  a  baby  who  is 
not  doing  well  is  a  very  delicate  task,  which  requires  a  great 
deal  of  painstaking  care,  and  much  time  and  thought  must  be 
given  to  it  if  good  results  are  to  be  obtained.  I  am  perfectly 
sure  that  after  you  have  used  these  methods  for  a  while  you  will 
have  no  trouble  whatever  with  them. 

/  wish  to  emphasize  'particularly  that  in  using  the  percentage 
method  it  is  not  necessary  to  calculate  the  percentages  loo  accurately, 
for  any  chain  is  only  as  strong  as  its  weakest  link,  and  it  is  non- 
sensical to  try  to  get  greater  accuracy  in  the  calculating  than  there 
is  in  the  percentage  of  the  milk  to  start  with,  or  in  the  methods  of 
mixing  it. 

The  idea  of  great  accuracy  in  calculation  is  one  that  has  been 
a  stumbling-block  to  many  beginners  in  percentage  feeding. 
At  the  next  lecture  we  will  take  up  the  feeding  of  the  premature 
and  normal  baby  and  a  discussion  of  the  various  proprietary 
foods. 


LECTURE  m 

THE  FEEDING  OF  NORMAL  INFANTS -THE  PROPRIE- 
TARY FOODS -PREMATURE  INFANTS 

THE  FEEDING  OF  NORMAL  INFANTS 

I  am  going  to  take  up  today  the  feeding  of  normal  babies  and 
children,  then  a  discussion  of  the  various  proprietary  foods, 
showing  their  advantages  and  disadvantages.  After  that,  if 
there  is  time,  I  shall  discuss  the  care  and  feeding  of  premature 
infants. 

Breast  milk  contains  4  percent  fat,  7  percent  sugar,  1.6  per- 
cent protein — a  food  relatively  rich  in  fat  and  sugar  and  poor 
in  protein.  It  is  reasonable  to  suppose  that  as  this  is  the  type 
of  food  nature  intended  for  infants,  the  best  artificial  food  for 
them  is  a  food  which  somewhat  approximates  breast  milk  in  its 
composition,  and  in  which,  especially,  the  proportion  of  one  ele- 
ment to  another  is  somewhat  the  same  as  it  is  in  breast  milk. 

We  do  not  try  to  exactly  imitate  breast  milk,  however.  Rather  do 
we  try  to  fit  the  milk  to  the  digestive  capacity  of  the  individual  baby, 
determining  this  capacity  by  watching  the  baby's  symptoms,  its 
weight,  and  by  carefully  examining  its  stools. 

The  feeding  of  any  baby  is  more  or  less  experimental  for  the 
first  few  feedings.  The  digestive  capacity  of  average  babies  of 
similar  size,  age,  and  weight  is  known ;  but  the  digestion  of  any 
particular  baby  is  at  first  an  unknown  quantity,  until  the  physi- 
cian becomes  better  acquainted  with  it,  so  the  baby  is  given  a 
milk  which  it  ought  to  be  able  to  take,  and  if  it  cannot  digest 
that,  the  food  has  to  be  altered  to  suit  the  capacity  of  its  diges- 
tion. It  is  very  important  in  all  artificial  feeding  to  fit  the  food 
to  the  baby.  The  baby,  and  not  rules  and  tables,  ought  to  be 
followed  in  artificial  feeding.  Remember  the  individual  baby 
and  certain  broad  general  principles  which  apply  to  all  babies. 

The  feeding  of  sick  babies  is  a  different  proposition  from  feed- 
ing well  babies.     Often  a  sick  baby  cannot  take  a  milk  that  is 

41 


42 


INFANT   FEEDING    (BOSTON   METHODS) 


anything  like  the  milk  a  well  baby  would  take.  More  than 
ever,  dealing  with  these  abnormal  cases,  does  the  food  have  to  be 
fitted  to  the  particular  digestive  and  absorptive  power  of  the 
individual  baby. 

How  often  is  a  baby  to  be  fed,  how  strong  a  food  is  it  to  take, 
how  much  of  it  in  the  twenty-four  hours,  and  how  much  at  each 
feeding? 

As  I  said  last  time,  this  varies  a  great  deal  for  different  babies. 
Two  babies  of  the  same  age,  size,  and  weight  may  take  entirely 
different  amounts  and  strengths  of  food  and  may  need  entirely 
different  intervals.  Especially  is  it  true  that  two  babies  of  the 
same  size  and  weight,  but  of  different  ages,  will  need  different 
foods.  The  older  baby  will  need  a  great  deal  more  food  and 
stronger  food  than  the  younger  baby.  In  general,  an  older  baby 
needs  more  calories  per  pound  of  body  weight  than  a  younger 
baby  of  the  same  size  and  weight. 

Now,  if  we  were  feeding  a  baby  rathei*  small  amounts  of  food, 
we  would  naturally  give  these  small  amounts  more  often.  If 
a  large  feeding  is  given  each  time,  the  intervals  should  be 
lengthened.  This  table  shows  what  most  well  babies  will  take 
and  the  most  usual  intervals  employed : 


Aqe 
Iwk.  . 

4  wks. 

4  mos. 

6-mos. 
9  mos. 


TwENTY-FOtlR- 

HOUB  Amount 
.  10-12  ounces 

20       " 

.       32       " 

.36-42      " 

.       48      " 


Number  of  Feedings,  Amount  and 
Intervals 


10  feedings  of  1      ounce  every  2 
8        "       "   1  jounces    "     23^ 

"  3 

«  4 

"  4M 
"  &-7 


hours 


2J^ 
3 

3 
3 
3 


(From  Morse  and  Talbot's  "Infant  Feeding.") 


Composition  of  Food 

Age  Fat  Sugar 

First  food 1.00  5.00 

First  week 2.00  6.00 

1  month 3.00  7.00 

2  months '. 3.00  7.00 

4  months 3.00  7.00 

6  months 3.50  7.00 

8  months 4.00  7.00 

lyear 4.00  4.50 


Protein 
0.50 
0.75 
1.20 
1.60 
1.80 
2.25 
2..50 
3.20  (whole  milk) 


THE  FEEDING  OF  NORMAL  INFANTS  43 

As  to  night  feedings,  most  babies,  or  at  least  a  great  many 
babies  over  four  or  five  months  old,  will  get  along  without 
any,  taking  their  feedings  from  six  in  the  morning  to  nine 
or  ten  at  night,  and  going  through  the  night  without  any  feed- 
ing until  the  next  morning.  In  general  it  is  a  bad  plan  to  allow 
the  baby  to  take  two  or  three  night  feedings  unless  there  is 
some  special  indication.  If  the  baby  is  atrophic  and  not  doing 
well,  of  course  it  will  probably  have  to  be  fed  through  the  night. 
But  it  is  a  good  plan  to  do  away  with  the  night  feeding  if  pos- 
sible, because  it  saves  so  much  trouble  to  the  parents,  and  most 
babies  can  get  along  without  any,  or  if  they  require  it  at  all,  they 
can  get  along  with  one  feeding  instead  of  two  or  three. 

Let  us  take  up  again  the  different  elements  of  the  food.  First, 
let  us  consider  the  fat.  It  is  always  unwise  to  feed  any  baby, 
no  matter  how  old,  on  more  than  4  percent  of  fat.  That  is  the 
Umit  of  fat  tolerance  for  practically  every  baby.  Most  babies 
will  not  be  able  to  take  even  this  amount.  Most  of  them,  until 
seven  or  eight  months  of  age,  will  get  along  better  on  3  percent 
than  on  4.  Some  babies  will  get  along  better  on  2  percent  than 
on  3. 

The  fat  in  the  milk  causes  more  trouble  than  any  other  ele- 
ment. More  babies  have  chronic  nutritional  disturbances  from 
a  difficulty  of  fat  absorption  than  from  any  other  cause. 

It  is  important  to  consider  what  percent  cream  is  being  used 
in  making  up  the  modification  if  the  gravity  cream  and  skimmed- 
milk  method  is  used.  It  is  not,  of  course,  correct  to  use  a  32  or 
20  percent  cream,  and  calculate  as  though  it  were  a  16  percent 
cream,  because  the  baby  may  be  getting  in  this  way  6  or  7  per- 
cent of  fat  when  the  feeding  is  supposed  to  contain  only  3  or 
4  percent.  In  calculating  fat  percentages  it  is  well  not  to  give 
any  baby  over  3  percent  of  fat  when  using  the  gravity  cream 
and  skimmed-milk  method  of  modification,  because  the  skimmed 
milk  inevitably  contains  a  small  amount  of  fat,  and  the  fat  per- 
centage will  be  higher,  in  using  this  method,  than  the  calcula- 
tion shows. 

Also,  throughout  this  particular  district  of  North  Carolina 
there  seem  to  be  a  great  many  Jersey  cows,  or  cows  of  part 
Jersey  blood.  It  must  always  be  remembered  that  Jersey  milk 
is  richer  in  fat  than  other  milks  are,  and  for  this  reason,  if  the 


44  INFANT  FEEDING    (BOSTON  METHODS) 

milk  of  a  Jersey  cow  has  to  be  used,  it  is  well  to  remove  part  of 
the  cream  before  making  up  the  milk  modification.  The  milk 
from  a  mixed  herd  is  Ukely  to  be  much  more  uniform  in  compo- 
sition than  is  the  milk  from  one  cow,  and  this  is  why  it  is  usually 
best  to  feed  a  baby  on  milk  from  a  mixed  herd,  if  it  can  be  ob- 
tained. 

Some  babies  who  cannot  take  milk-fat  well  are  able  to  take 
oUve  oil,  and  in  such  cases  it  is  well  to  give  a  teaspoonful  of 
oHve  oil  three  or  four  times  a  day  rather  than  give  so  much  fat 
in  the  milk.  Rubbing  the  baby  with  oil  does  not  do  much  good, 
because  there  is  practically  no  absorption  through  the  skin. 
This  merely  keeps  the  skin  in  good  condition  and  does  not  act 
as  a  food  for  the  baby. 

Recently  there  has  come  into  use  what  is  called  homogenized 
milk.  It  is  made  by  intimately  mixing  olive  oil  and  skimmed 
milk  by  forcing  them  through  a  valve  under  considerable  pres- 
sure. The  oil-globules  are  broken  up  and  made  very  small, 
and  this  milk  is  often  much  better  digested  than  any  other  in 
certain  cases  of  chronic  fat  indigestion,  where  the  baby  cannot 
take  the  milk-fat.  I  am  sure  this  milk  will  be  available  to  every- 
body in  a  few  years,  but  it  is  not  at  present,  so  this,  for  you 
gentlemen,  now  is  a  matter  of  theoretical  interest  rather  than 
of  practical  importance. 

Let  us  consider  next  the  sugar.  There  are  a  number  of  differ- 
ent sorts  of  sugar.  There  are  lactose,  or  milk-sugar;  sucrose, 
or  cane-sugar;  and  maltose,  or  malt-sugar.  These  are  the  three 
sugars  used  in  practical  infant  feeding.  Ordinary  lactose,  or 
milk-sugar,  is  the  best  for  feeding  most  normal  babies.  It  may 
be  split  up  in  the  intestine  into  acids,  and  when  it  ferments,  is 
likely  to  be  rather  laxative.  Sucrose  has  ordinarily  no  advan- 
tage over  lactose  except  that  it  is  cheaper.  Generally  it  is 
better  not  to  feed  babies  on  sucrose  if  one  of  the  other  sugars  is 
available. 

Maltose  is  never  given  pure.  Pure  malt-sugar  is  very  ex- 
pensive and  hard  to  obtain.  Malt-sugars  and  the  various  malted 
foods  consist  of  part  dextrins  and  part  malt-sugar.  Some  of 
these  preparations  which  we  must  consider  are  as  follows : 


THE   FEEDING   OF   NORMAL   INFANTS  45 

Composition 
Maltose  Dextrins 

Meade's  Dextri-maltose 51  percent  47  percent 

MelUn'sFood 58       "  20       " 

Maltine  Malt  Soup 62       "  3       " 

Loeflund's  Malt  Soup  Extract..  59      "  15       " 

Maltose  is  more  readily  absorbed  than  lactose,  and  its  as- 
similation limit  is  higher;  that  is,  a  baby  can  take  more  maltose 
without  showing  sugar  in  the  urine  than  it  can  lactose  or  sucrose. 
Malt-sugar  ferments  less  readily  than  does  lactose,  and  for  this 
reason  a  malt-sugar  preparation  is  often  of  value  in  feeding 
certain  cases  of  sugar  indigestion  or  fermentative  diarrhea. 
Malt-sugar  is  also  ordinarily  the  best  sugar  to  use  in  feeding 
cases  of  convalescent  infectious  diarrhea.  All  the  malt-sugar 
preparations  consist  of  combinations  of  maltose  and  dextrins. 
If  the  proportion  of  maltose  is  high  in  comparison  with  the  dex- 
trins, the  food  is  likely  to  be  laxative;  if  the  proportion  of 
dextrins  is  relatively  high,  it  is  likely  to  be  constipating.  Dextri- 
maltose,  on  account  of  its  high  content  of  dextrins,  is  somewhat 
constipating;  the  other  malt-sugar  preparations  are  laxative. 
The  various  malt-sugar  preparations  are  of  unquestionable 
value  in  feeding  certain  cases ;  but  two  things  must  be  remem- 
bered about  them: 

1.  Some  babies  may  have  an  idiosyncrasy  to  maltose  and  not 
be  able  to  take  it  at  all  well,  so  it  is  by  no  means  a  universal 
panacea  for  all  sugar  troubles,  as  a  good  many  people  seem  to 
think. 

2.  It  is  to  be  distinctly  remembered  that  none  of  the  malt-sugar 
preparations  or  "malted  foods ^'  are  complete  foods,  and  that  their 
proper  role  in  infant  feeding  is  simply  as  sugars,  as  substitutes  for 
lactose — when  substitution  of  a  malt-sugar  is  indicated. 

Now  let  us  take  up  starch.  It  has  been  proved  a  good  many 
times  that  new-born  babies  can  digest  starch,  but  they  should 
not  ordinarily  be  fed  this,  because  in  practical  use  starch  in  any 
considerable  quantity  does  not  agree  with  them.  I  always  start 
giving  barley  water  in  the  milk  when  the  baby  is  about  six  or 
seven  months  old.  It  furnishes  a  little  extra  nourishment,  it 
teaches  the  baby  how  to  digest  starch,  and  aids  in  the  digestion 
of  milk  casein  by  tending  to  prevent  the  formation  of  large  curds. 
Any  one  of  the  ordinary  barley  flour  preparations  on  the  market 


46  INFANT  FEEDING    (BOSTON   METHODS) 

may  be  used.  A  tablespoonful  to  a  pint  of  water  gives  a  1.5 
percent  suspension  of  starch.  The  best  amount  to  use  is  ordi- 
narily about  0.75  percent  starch  in  the  milk  mixture,  as  it  has 
been  found  that  this  is  the  optimum  amount  to  prevent  the  fqr- 
mation  of  large  casein  curds. 

"Barley  jelly"  is  of  very  great  value  in  infant  feeding;  it 
consists  merely  of  a  thick  barley  gruel,  and  may  be  prepared 
as  follows: 

Add  four  tablespoonfuls  of  barley  flour  to  a  pint  of  water; 
cook  in  a  double  boiler  one  hour,  strain  to  get  rid  of  lumps;  add 
enough  water  to  make  up  to  a  pint  again,  salt  to  taste,  and  set 
on  ice.  The  resulting  product  is  a  very  thick  gruel,  and  is  fed 
to  babies  eleven  or  twelve  months  old.  It  is  especially  of  use 
as  the  first  semisolid  food  after  infectious  diarrhea. 

"Oatmeal  jelly"  is  also  of  considerable  value,  especially  in 
feeding  constipated  babies  over  a  year  old.  It  is  prepared  as 
follows: 

Oatmeal,  4  ounces;  water,  1  pint.  Boil  four  hours  in  a 
double  boiler.  Add  water  to  form  a  thin  paste.  Force  through 
a  colander  while  still  hot  to  get  rid  of  coarse  particles,  and  salt 
to  taste. 

The  protein  in  the  milk  is  very  important  because  it  is  a  tissue 
builder.  It  keeps  the  baby's  body  in  a  state  of  nitrogenous 
equiHbrium,  and  every  baby  has  to  have  it  to  keep  well.  The 
chief  trouble  with  the  protein  in  cow's  milk  is  that  it  fonns  large 
curds  in  the  stomach  which  are  hard  to  digest.  Generally  the 
protein  in  the  milk  causes  very  Uttle  trouble,  as  it  is  always 
easy  to  modify  it  in  such  a  way  that  no  tough  curds  will  be 
formed  in  the  stomach. 

One  way  to  do  this  is  to  give  whey  mixtures  instead  of  casein 
mixtures.     Whey  has  this  composition: 

Fat  0.0  percent  Sugar  4.5  percent  Protein  0.9  percent 

and  all  the  protein  is  in  the  form  of  "whey"  protein,  which  is 
very  easily  digested  and  is  not  coagulated  in  the  stomach.  So 
if  a  baby  vomits  and  does  not  digest  fat  and  protein  well,  whey 
may  be  used,  and  most  babies  can  easily  digest  it.  A  good  many 
babies  are  able  to  take  whey  when  they  cannot  take  anything 
else;  but  it  should  be  remembered  that  whey  is  a  very  weak 


THE   FEEDING   OF   NORMAL   INFANTS  47 

food  and  furnishes  little  nourishment  to  the  baby,  so  is  of  value 
only  as  a  temporary  and  not  as  a  permanent  food.  If  it  is  de- 
sired to  increase  the  food  value  of  whey,  fat  may  be  added  to  it 
in  the  form  of  16  percent  cream. 

Whey  is  prepared  as  follows:  To  one  pint  of  lukewarm  milk 
add  two  teaspoons  of  Fairchild's  essence  of  pepsin ;  stir  and  mix. 
Let  it  stand  until  the  milk  has  "jellied,"  and  then  beat  it  with 
a  fork  to  separate  the  curd  into  fine  particles.  Strain — best 
through  cheese-cloth.  The  liquid  which  comes  through  is  the 
whey.     One  quart  of  milk  furnishes  about  24  ounces  of  whey. 

Some  of  the  other  methods  for  preventing  the  formation  of 
large  curds  are  as  follows: 

1.  Addition  of  cereal  diluents. 

2.  Boiling. 

3.  Peptonization.  » 

4.  Addition  of  alkahs. 

1.  The  addition  of  a  cooked  starch  preparation,  such  as  barley 
water,  to  a  milk  modification,  tends  to  prevent  the  formation  of 
large  tough  curds  in  the  stomach.  About  0.75  percent  of  starch 
in  a  mixture  is  enough  to  give  this  action. 

2.  Boiling  vigorously  for  five  or  six  minutes  produces  certain 
chemical  changes,  which  to  a  considerable  extent  prevent  coagu- 
lation. 

3.  Peptonization  of  milk  prevents  the  formation  of  a  curd  in 
the  stomach,  and  also,  to  a  certain  extent,  predigests  the  milk. 
Milk  should  always  be  peptonized  when  being  fed  by  rectum, 
but  usually  it  is  not  necessary  to  peptonize  milk  for  ordinary 
feeding,  because  there  are  so  many  easier  ways  of  preventing 
curd  formation. 

4.  The  addition  of  an  alkali,  in  sufficient  amount,  to  the  milk 
prevents  curd  formation.     The  alkalis  which  may  be  used  are: 

Lime-water. 

Sodium  citrate. 

Sodium  bicarbonate. 
For  practical  purposes  lime-water  is  the  best  alkali  to  use, 
although  there  is  certain  evidence  to  show  that  the  use  of  lime- 
water  interferes  somewhat  with  fat  absorption,  and  in  cases 
where  the  fat  assimilation  is  poor,  it  should  probably  not  be 
given. 


48  INFANT  FEEDING    (BOSTON  METHODS) 

Lime-water  must  be  given  in  a  strength  of  from  25  to  50  per- 
cent of  the  milk  or  milk  and  cream  used  in  the  mixture,  if  it  is 
to  have  any  appreciable  effect.  The  giving  of  small  amounts  of 
Ume-water  does  no  good. 

Sodium  citrate  is  a  valuable  alkali  to  use  to  prevent  curd  for- 
mation. Two  grains  of  the  citrate  to  one  ounce  of  milk,  or  milk 
and  cream,  is  the  amount  ordinarily  used. 

Sodium  bicarbonate  is  used  in  the  same  strength  as  sodium 
citrate,  but  has  this  disadvantage :  it  tends  to  upset  the  baby's 
stomach  and  may  cause  it  to  vomit. 

I  want  to  speak  briefly  of  ''Eiweiss,"  or  protein  milk,  of  which 
you  have  all  probably  heard.  The  Germans  devised  this  milk 
a  few  years  ago,  in  order  to  get  a  milk  with  a  relatively  high 
protein  and  low  fat  and  sugar  content  for  use  in  fermentative 
diarrhea.  It  works  very  well.  The  great  trouble  is  that  it  is 
hard  to  prepare,  as  you  will  see  from  the  directions  given  below, 
and  many  people  cannot  do  it  satisfactorily. 

One  quart  of  whole  milk  is  heated  to  100°  F.  Add  four 
tablespoons  of  essence  of  pepsin,  and  stir.  Let  it  stand  at  100° 
F.  until  a  curd  has  formed,  and  strain  off  the  whey  from  the 
curd.  Press  the  curd  through  a  fine  sieve  three  or  four  times. 
Add  one  pint  of  water  to  the  curd  and  one  pint  of  buttermilk  to 
this  mixture. 

For  all  practical  purposes  it  consists  then  of  a  pint  of  butter- 
milk, a  pint  of  water,  and  curd  from  a  quart  of  milk.  It  contains 
about  2.5  percent  fat,  1.5  percent  sugar,  3  percent  protein. 
It  can  be  used  if  one  is  deahng  with  an  intelligent  family  who 
will  take  the  trouble  to  make  it. 

If  the  baby  does  not  take  fat  well,  it  is  best  to  skim  the  milk 
used  in  making  the  curd. 

There  is  a  product  on  the  market  called  Larosan  which  is 
a  good  deal  easier  to  use  than  this  Eiweiss  milk.  It  is  in  the 
form  of  a  powder,  which  can  be  added  to  a  milk  mixture  to  give  a 
high  protein  percentage.  It  is  a  practical  thing  to  use,  and  a 
great  many  babies  with  fermentative  diarrhea  will  do  extremely 
well  on  it.  The  trouble  is  that  the  war  has  interfered  with  its 
production,  and  it  is  now  extremely  hard  to  get. 

Let  us  consider  buttermilk  for  a  moment.  It  has  about  this 
composition:   1  to  0.5  percent  fat,  about  3  percent  sugar,  and 


PROPRIETARY   FOODS  49 

about  2.5  percent  protein.  The  protein  is  in  a  precipitated 
form,  which  cannot  be  coagulated  again  in  the  stomach,  and 
there  is  a  very  low  sugar  percentage.  There  is  also  lactic  acid, 
which  tends  to  prevent  fermentation  or  putrefaction.  These 
are  the  advantageous  points  of  buttermilk.  Lactic  acid  bacillus 
or  "bulgaricus"  cultures  are  of  great  value  in  preparing  lactic 
acid  milk.  I  am  somewhat  skeptical,  however,  about  many  of 
the  tablets  which  are  put  on  the  market,  and  do  not  believe  they 
are  as  efficient  as  the  hquid  cultures  or  as  ordinary  buttermilk. 
Buttermilk  is  often  of  very  great  value  in  feeding  babies.  The 
trouble  with  it  is  that  it  is  hard  to  tell  whether  or  not  it  is  good 
buttermilk.  It  may  be  full  of  all  sorts  or  other  bacteria  besides 
the  lactic  acid  bacteria.  If  liquid  cultures  are  used,  however, 
and  one  makes  one's  own  lactic  acid  milk,  one  can  be  sure  of 
getting  a  clean  preparation. 

PROPRIETARY  FOODS 

The  proprietary  foods  have  certain  good  points  and  a  great 
many  bad  points.  Of  course,  in  certain  districts  where  cow's 
milk  cannot  be  obtained  the  proprietary  foods  have  to  be  used; 
but  in  general  the  indiscriminate  use  of  proprietary  foods  has 
done  more  harm  than  good,  because  they  are  usually  prescribed 
without  any  knowledge  whatever  of  their  composition.  Most 
of  them  are  of  such  composition  that  they  do  not  give  a  baby  a 
well-balanced  ration,  and  may  be  of  value  to  add  to  a  milk  modi- 
fication, hut  not  to  use  as  a  complete  food.  The  great  trouble  with 
most  of  the  proprietary  foods  is  that  their  sugar  content  is  far 
too  high  in  proportion  to  the  fat  and  protein  content.  Most 
babies  fed  exclusively  on  condensed  milk  or  on  one  of  the  pro- 
prietary foods  for  any  length  of  time  get  into  trouble  sooner  or 
later.  Proprietary  foods  cannot  contain  anything  that  milk 
cannot  contain,  and  if  one  knows  how  to  modify  milk,  anything 
can  be  put  into  it  that  is  in  any  proprietary  food. 

I  do  not  mean  to  give  the  impression  that  proprietary  foods 
should  never  be  used,  for  this  is  not  so;  but  I  do  mean  that  if 
they  are  to  be  used  their  composition  must  be  known  in  order  to 
know  the  amount  of  each  food  element  the  baby  is  taking,  and 
to  be  sure  that  it  is  getting  a  well-balanced  ration.  In  most  of 
4 


50  INFANT  FEEDING    (BOSTON  METHODS) 

the  proprietary  foods  the  vitamins  are  destroyed :  these  vitam- 
ins are  necessary  for  the  baby's  proper  development.  This  is 
another  reason  why  it  is  wrong  to  feed  a  baby  exclusively  on 
condensed  milk  or  any  other  proprietary  food  for  any  length  of 
time. 

For  many  years  many  people  have  tried  to  produce  a  universal 
infant  food  which  will  be  a  perfect  substitute  for  breast  milk  and 
which  can  be  fed  to  any  baby.  Such  a  food  will  never  be  pro- 
duced; what  is  food  for  one  baby  may  be  poison  for  another, 
and  any  artificial  food  must  always  be  fitted  to  the  digestive 
capacity  of  the  individual  infant.  There  is  no  such  thing  as  a 
universal  infant  food  upon  which  all  babies  can  be  fed,  except 
breast  milk,  and  there  never  will  be. 

If  proprietary  foods  are  used,  their  composition  should  be 
known.  There  are  five  classes  of  proprietary  foods,  which  may 
be  roughly  divided  as  follows : 

1.  Condensed  milks  and  evaporated  milks. 

2.  Malted  foods. 

3.  Malted  foods  containing  starch. 

4    Starchy  foods,  containing  practically  nothing  but  starch. 

5.  The  various  "dry  milk"  powders. 

In  class  1  belong  the  ordinary  sweetened,  thick  condensed 
milks  and  unsweetened  evaporated  milks.  To  the  second  class 
belong  Mellin's  Food,  HorHck's  Malted  Milk,  etc.  (Horlick's 
Malted  Milk  is  not  exactly  like  Mellin's  Food  in  composition, 
as  its  basis  is  a  dried  milk  preparation  to  which  considerable 
maltose  and  dextrins  have  been  added;  but  in  practical  use  it 
may  be  considered  to  be  much  the  same  sort  of  preparation  as 
Mellin's  Food.)  In  class  3  is  Eskay's  Food;  in  class  4,  Ridge's 
Food  and  Imperial  Granum,  and  in  class  5  "Kindolac"  is  a  fair 
representative  of  the  group. 

The  condensed  milks  have  all  practically  the  same  percentage 
composition.     The  average  composition  is  about  as  follows : 

Fat  9  percent  Sugar  55  percent  Protein  8  percent 

This  is  a  very  poorly  balanced  ration,  because  there  is  too 
much  sugar  for  the  fat  and  protein.  When  the  sugar  is  reduced 
by  dilution  with  water  to  the  proper  percentage,  the  fat  and  the 
protein  are  reduced  too  much,  and  the  baby  does  not  get  enough 


PROPRIETARY    FOODS  51 

to  eat.     One  part  of  condensed  milk  and  two  parts  of  water  give 
these  percentages: 

Fat  3  percent  Sugar  18  percent         Protein  2.6  percent 

The  fat  and  the  protein  would  be  about  right  in  this  mixture 
for  some  babies,  but  few  babies  can  take  18  percent  of  sugar  for 
any  length  of  time  without  getting  into  trouble.  If  the  con- 
densed milk  is  diluted  with  four  parts  of  water,  this  percentage 
results : 

Fat  1.8  percent        Sugar  11  percent        Protein  1.6  percent 

Condensed  milk  is  usually  diluted  more,  and  the  dilution  I 
have  generally  seen  used  is  one  part  of  condensed  milk  to  six 
parts  of  water.  That  would  give  a  very  weak  mixture,  with 
Uttle  nourishment  for  the  baby.  With  eight  parts  of  water  the 
fat  would  be  1,  sugar  6,  and  protein  0.9.  The  reason  why  con- 
densed milk  is  so  much  in  favor  is  that  a  great  many  babies  who 
have  been  fed  on  too  strong  or  improperly  modified  cow's  milk 
can  take  diluted  condensed  milk  simply  because  it  -is  so  dilute 
that  it  is  no  tax  to  their  digestions.  Still  they  are  not  getting 
enough  to  eat.  I  have  noticed  that  there  is  an  opinion  prevalent 
among  many  of  the  laity  here  that  cow's  milk  is  impossible  for 
many  babies  to  take,  especially  in  the  summer,  and  that  con- 
densed milk  is  the  thing  always  to  give  them  if  they  become  up- 
set on  cow's  milk.  Of  course  this  is  absolutely  fallacious ;  there 
are  certain  rare  cases  in  which  a  baby  shows  an  idiosyncrasy  to 
cow's  milk  and  can  never  take  it  without  disturbance,  but  these 
cases  are  very,  very  uncommon,  and  almost  always  when  a 
mother  says  "the  bahyy cannot  take  cow's  milk"  it  is  simply 
because  the  milk  haa'^ot  been  modified  properly  to  suit  the 
baby's  digestion.  Iv  cow's  milk  is  modified  properly  and  is 
reasonably  clean,  most  babies  can  take  it  as  well  as  they  can 
condensed  milk  or  any  other  proprietary  food.  Condensed 
milk  may  be  of  value  occasionally  to  tide  'a  baby  over  for  a 
few  days  when  a  very  weak  food  is  desired,  hut  it  is  absolutely 
unsuitable  as  a  food  for  any  baby  whatever  over  long  periods  of  time. 

The  unsweetened  evaporated  milks  have  a  better  composition 
than  the  condensed  milks.  The  percentage  composition  of  most 
of  them  is  this : 

Fat  9  percent  Sugar  10  percent  Protein  7  percent 


52  INFANT  FEEDING    (BOSTON   METHODS) 

One  part  of  evaporated  milk  to  three  of  water  gives  this  per- 
centage: 

Fat  2.25  percent        Sugar  2.5  percent        Protein  1.7  percent 
A  1  to  4  dilution  gives: 

Fat  1.8  percent  Sugar  2  percent  Protein  1.4  percent 

Milk-  or  malt-sugar  should  be  added  to  evaporated  milk  dilu- 
tions to  bring  up  the  sugar  percentage.  These  evaporated 
milks  are  much  better  to  use  than  condensed  milks,  and  are 
the  preparations  to  be  used  if  fresh  cow's  milk  cannot  be  ob- 
tained. 

HorUck's  Malted  Milk  has  this  composition: 

Fat  9  percent  Sugar  67  percent  Protein  16  percent 

Its  basis  is  dried  milk,  to  which  maltose  and  dextrins  have  been 
added.     Mellin's  Food  contains: 

Fat  0.16  percent       Sugar  80  percent  Protein  10  percent 

These  foods  are  occasionally  valuable  in  infant  feeding  to 
use  as  sugars  to  correct  constipation,  as  the  malt-sugar  which 
they  contain  is  mildly  laxative.  It  must  be  remembered  that 
they  are  not  complete  foods,  and  should  not  be  used  as  such; 
whatever  value  they  have  is  in  their  content  of  maltose  and 
dextrins. 

The  third  class  of  foods  contain  a  certain  amoimt  of  starch  in 
addition  to  the  other  constituents.  Eskay's  Food  is  an  example 
of  this  group,  and  contains 

Fat  3.5  percent    Sugar  55  percent    Starch  29  percent    Protein  6.7  percent 

It  is  valueless  unless  used  simply  as  a  sugar  or  starch  would  be 
used,  as  an  addition  to  fresh  cow's  milk,  because  when  it  is 
diluted  with  water  the  baby  gets  practically  nothing  but  carbo- 
hydrates. 

Imperial  Granum,  which  belongs  to  the  fourth  class,  consists 
mostly  of  starch,  part  of  which  has  been  dextrinized.  It  may 
be  used  in  the  same  way  that  barley  flour  preparations  are 
used. 


PROPRIETARY   FOODS  53 

"Kindolac"  is  a  "dried"  Dailk,  belonging  to  the  fifth  class. 
Its  composition  is: 

Fat  13  percent         Sugar  61  percent         Protein  19  percent 

Generally  speaking,  the  trouble  with  most  of  the  dried  milk 
preparations  is  that  they  do  not  contain  enough  fat,  as  a  high 
fat  content  interferes  with  the  drying  process.  So  much  for  a 
few  of  the  proprietary  foods.  As  a  brief  general  sununary  it  is 
fair  to  say  this : 

Most  of  the  proprietary  foods  do  not  contain  a  suitable  balance 
of  the  several  food  elements  to  allow  them  to  be  used  as  complete 
foods  for  any  baby;  the  carbohydrate  content  is  usuxilly  high — out 
of  all  proportion  to  the  fat  and  sugar.  If  they  are  used  at  all,  they 
should  be  used  as  substitutes  for  su^ar  in  the  modification  of  fresh 
milk.  It  is  necessary  always  in  using  any  proprietary  food  to 
know  approximately  its  composition. 

When  can  a  baby  take  solid  food?  As  the  first  soUd  food  that 
it  usually  takes  is  cereal  or  bread,  it  is  well  to  add  barley  water 
to  the  milk  of  most  babies  when  they  are  six  or  seven  months 
old  in  order  to  have  them  get  used  to  starch.  When  the  baby  is 
nine  months  old,  it  can  have  a  piece  of  dry  toasted  bread  or 
zwieback  to  hold  in  its  hand  and  chew  on  occasionally.  When 
it  is  ten  months  old,  give  it  a  couple  of  tablespoonfuls  of  barley 
jelly  or  of  farina  during  the  day.  At  a  year  old  the  baby  should 
be  put  on  four-hourly  feeding  intervals,  at  7,  11,  2,  and  6,  and 
the  twenty-four-hourly  quantity  of  milk  should  be  limited  to  a 
quart.  It  is  a  great  mistake  to  give  a  baby  who  is  over  a  year  old 
too  much  milk;  at  this  period  of  its  development  it  is  beginning  to 
need  solid  food,  and  if  too  much  milk  is  given,  the  appetite  for  solid 
food  is  likely  to  be  lost.  Most  babies  of  eleven  or  twelve  months 
can  take  whole  milk  undiluted,  and  in  addition  farina  or  barley 
or  oatmeal  jelly  and  zwieback.  Chicken  or  mutton  soup  (with 
the  fat  removed),  beef-juice,  and  prune-juice  or  orange-juice 
may  also  be  given.  At  about  sixteen  months  most  babies  can 
begin  to  take  eggs  and  potatoes.  The  egg  should  be  soft 
boiled  or  coddled,  and  not  more  than  a  teaspoonful  should  be 
given  at  first,  as  sometimes  eggs  cause  severe  upsets  in  small 
babies  when  they  first  start  to  take  them.  It  is  a  bad  mistake 
to  feed  eggs  to  most  babies  under  fifteen  or  sixteen  months.     If  the 


54  INFANT   FEEDING    (BOSTON  METHODS) 

baby  seems  to  be  able  to  take  the  egg  well,  the  amount  can  be 
gradually  increased  until  it  is  taking  one  egg  every  other  day. 
Potato  is  best  given  as  mashed  potato,  and  this  should  be  well 
mashed,  with  a  good  deal  of  milk  added,  so  that  there  are  no 
large  lumps,  which  almost  always  go  through  the  baby  undi- 
gested. At  two  years  of  age  a  baby  can  be  given  finely  chopped 
meat:  lean  beef,  chicken,  and  mutton  are  the  best  meats  to  use. 
At  about  this  same  time  green  vegetables  may  be  given,  but  it  is 
very  important  to  remember  that  these  must  be  thoroughly 
cooked  and  mashed  or  well  chopped,  so  that  the  indigestible 
cellulose  portion  will  not  irritate  the  baby's  intestine.  Peas, 
beans,  stewed  carrots  or  celery,  and  asparagus-tips  may  be  given 
in  this  way. 

As  to  fruit,  I  must  write  it  in  italics :  Green  fruit  of  any  sort 
should  not  be  given  to  any  child  whatsoever  under  four  years  of  age. 
There  certainly  are  some  babies  who  seem  to  be  able  to  eat 
anything  and  not  be  upset  by  it,  but  for  most  babies  green  fruit 
or  green  vegetables,  improperly  prepared,  are  absolutely  con- 
traindicated. 

Even  after  four  years  of  age,  and  well  along  into  childhood, 
the  use  of  fruits  should  be  considerably  restricted,  and  if  they 
are  eaten,  special  care  should  be  taken  that  no  skins,  rinds,  or 
cores  are  swallowed.  Of  course,  at  about  two  years  a  child 
may  take  a  moderate  amount  of  properly  prepared  stewed  fruit, 
such  as  prunes,  peaches,  or  apricots.  Never  give  any  child  a 
whole  orange;  the  juice  of  the  orange  is  good  for  him,  the  rest 
of  it  is  not.  Small  amounts  of  ripe  raw  scraped  apple  are  also 
good  for  some  babies  as  an  antiscorbutic  when  orange-juice 
cannot  be  obtained. 

The  diet  Ust  of  the  Children's  Hospital,  Boston,  for  babies  of 
about  eighteen  months,  is  as  follows: 

Milk  Milk-toast  Baked  potato 

Butter  Zwieback  Plain  macaroni 

Mutton  broth  Plain  crackers  Orang^e-juice 

Chicken  broth  Barley  jelly  Baked  apples 

Beef-juice  Oatmeal  jelly  Stewed  prunes 

Soft-boiled  eggs  Cream  of  Wheat  Baked  custard 

Dropped  eggs  Farina  Corn-starch  pudding 

Toasted  bread  Rice  Blanc-mange 


PROPRIETARY   FOODS  55 

The  following  diets  are  taken  from  that  splendid  little  book  of 
Dr.  Richard  Smith's,  "The  Baby's  First  Two  Years": 

Diet  at  Thirteen  or  Fourteen  Months 

6.30-7.00:  Strained  cereal  or  gruel,  2  or  3  ounces 
Milk,  8  ounces 
8.30:  Orange-juice 
10.00-10.30:  Milk,  8  ounces 

2  zwieback  or  plain  cracker 
1.30-2.00:  Broth  or  beef-juice 

Rice  or  macaroni  or  spaghetti 
Bread  or  toast  or  cracker 
Milk,  4  to  5  ounces 
5.30:  Milk,  8  ounces 
Cereal  or  gruel 
Apple-sauce  or  prune- juice 

Diet  at  Sixteen  to  Eighteen  Months 

7.00:  Cereal 

Bread  and  butter 

Milk,  8  ounces 
8.30:  Orange- juice 
10.00-10.30:  Milk,  8  ounces 

Cracker  or  toast 
1.30:  Egg  or  beef -juice  or  scraped  beef  or  minced  chicken 

Potato  or  rice  or  macaroni  or  spaghetti 

Bread  and  butter 

Simple  dessert  (custard,  junket,  tapioca) 

Milk,  4  or  5  ounces 

Diet  at  Twenty  to  Twenty-two  Months 

6.30-7.00:  Orange-juice 
7.00-7.30:  Cereal 

Egg 

Bread  and  butter 

Milk 
10.30:  Milk 

Cracker  or  bread 
1.30:  Meat 

Potato 

Green  vegetable  (pur^e) 

Bread  and  butter 

Simple  dessert 
5.30:  Cereal 

Milk 

Bread  and  butter  * 

Fruit-sauce 

*  Bread  at  least  two  days  old;  butter  spread  very  thin. — L.  W.  H. 


66  INFANT  FEEDING    (BOSTON  METHODS) 


PREMATURE  BABIES 

Now  I  want  to  talk  for  a  little  while  about  premature  babies. 
Two  things  have  to  be  remembered  in  dealing  with  premature 
babies:  first,  that  a  premature  baby  must  be  kept  warm,  and 
secondly,  its  digestion  is  extraordinarily  feeble,  so  it  must  be 
given  very  weak  milk  mixtures. 

Incubators  were  formerly  thought  to  be  of  great  value  in  the 
care  of  premature  babies,  but  have  now  been  discarded  by  most 
pediatricians.  A  small  crib,  with  padded  sides  to  prevent 
drafts,  is  the  best  place  in  which  to  keep  a  premature  baby. 
There  should  be  a  thermometer  kept  in  this  crib,  and  the  tem- 
perature should  be  between  90°  and  95°  F. ;  the  rectal  tempera- 
ture should  be  taken  two  or  three  times  a  day  to  be  sure  that 
the  baby's  body-heat  is  kept  up.  If  the  rectal  temperature 
varies  between  98°  and  100°  F.,  there  is  no  cause  for  any  change 
in  the  heating  arrangements.  A  premature  baby  should  not 
be  washed  with  water,  but  should  be  oiled  with  warm  olive  oil 
and  wrapped  in  cotton  wool  or  a  gown  made  of  cotton  wool 
between  two  layers  of  very  soft  cheese-cloth.  It  is  well  not  to 
use  any  diapers  on  a  premature  baby,  but  to  put  a  pad  of  cotton 
wool  between  its  legs,  and  simply  change  it  when  it  is  dirtied. 
The  reason  for  this  is  that  premature  babies  bear  handling  very 
poorly;  the  less  they  are  handled,  the  better  off  they  are. 
Don't  weigh  the  baby  often — it  bothers  it  too  much;  once  a 
week  is  enough.  Premature  babies  seem  to  get  along  better  if 
their  air  supply  is  moist,  so  it  is  of  advantage  to  keep  a  little 
alcohol  or  electric  lamp  going  in  the  room,  with  a  shallow  vessel 
of  water  over  it,  to  secure  the  necessary  moisture.  The  tem- 
perature of  the  room  should  be  about  80°  F.  A  premature 
baby  needs  reasonably  clean  air  as  much  as  anybody  else  does, 
so  be  sure  that  the  room  is  properly  ventilated  and  not  kept 
hermetically  sealed  to  fresh  air  all  the  time. 

Get  breast  milk,  if  possible,  for  a  premature  baby.  In  most 
cases,  of  course,  it  must  be  obtained  from  some  woman  other 
than  the  mother.  If  the  baby  is  born  at  six  or  seven  months, 
the  mother  probably  will  not  have  enough  milk,  but  if  the  baby 
is  born  nearly  at  full  term,  perhaps  she  will  have.  Give  the 
premature  baby  very  weak  food  at  first.     It  can  scarcely  be  too 


PREMATURE   BABIES  57 

weak  to  start  with.  The  food  on  which  a  premature  baby 
should  be  started  is  breast  milk,  one-half,  and  a  3  percent  sugar 
solution,  one-half.  Give  a  dram  at  a  feeding  every  two  hours 
for  the  first  twenty-four  hours  of  the  baby's  life,  and  start 
feeding  when  it  is  twelve  hours  old.  The  stomach  of  a  baby 
born  at  term  holds  about  one  ounce,  therefore  the  capacity  of 
the  stomach  of  a  premature  baby  can  be  judged.  If  the  baby 
is  doing  well,  taking  its  food  well,  and  if  it  seems  hungry,  the 
amount  can  gradually  be  increased.  Most  premature  babies, 
if  they  are  doing  well,  can  take  undiluted  breast  milk  when  from 
a  week  to  ten  days  old. 

Of  course  a  dram  at  a  feeding  of  such  a  weak  mixture  as  we 
have  spoken  of  is  not  enough  to  cover  the  caloric  needs  of  the 
baby;  but  premature  babies  do  not  have  digestions  which 
correspond  with  their  theoretical  caloric  needs,  and  this  is  the 
difficulty.  One  of  these  babies  must  be  fed  what  it  can  take, 
and  not  what  it  ought  to  have  to  get  fat  on. 

The  dram  feedings  may  be  necessary  only  for  the  first  few 
feedings,  after  which  the  amount  may  be  increased.  The 
amount  should  be  increased  before  the  strength  of  the  food  is 
increased. 

If  a  premature  baby  is  born  nearly  at  term,  it  is  possible  that 
it  will  be  able  to  take  the  breast,  but  most  of  them  are  too  weak 
to  suckle  satisfactorily;  so  it  is  usually  necessary  to  pump  the 
breast  milk  and  to  feed  it  with  a  Breck  feeder  or  a  large  medi- 
cine-dropper. A  Breck  feeder  is  nothing  but  a  big  medicine- 
dropper  which  has  a  fancy  name  and  costs  a  dollar  and  a  quarter. 

The  use  of  a  medicine-dropper  apphes  equally  to  premature 
babies  who  are  fed  on  modified  cow's  milk,  as  well  as  to  those 
who  are  taking  breast  milk. 

It  lessens  the  chances  of  survival  for  a  premature  baby  if  it 
has  to  be  fed  on  cow's  milk,  but  in  many  cases  this  has  to  be 
done. 

The  best  percentage  to  start  with  is — 

Fat  1  percent  Sugar  4  percent  Protein  0.5  percent 

or  it  can  be  started  on  one-half  whey  and  one-half  4  percent 
sugar  solution,  adding  a  small  amount  of  16  percent  cream  to 
give  a  little  fat  as  the  baby  gets  older. 


58  INFANT  FEEDING    (BOSTON  METHODS) 

If  premature  babies  have  trouble  with  their  digestions, — 
vomiting  or  loose  bowels, — they  should  not  be  starved  or  given 
a  cathartic,  as  they  do  not  stand  either  of  these  procedures  at 
all  well.  The  treatment  of  indigestion  in  prematures  is  to  cut 
down  the  strength  or  amount  of  the  food  or  to  lengthen  the  in- 
tervals of  feeding.  It  is  especially  important  to -guard  the 
premature  baby  against  infections  of  any  sort ;  what  might  not 
hurt  another  baby,  such  as  a  shght  cold  in  the  head  or  a  mild 
bronchitis,  might  prove  fatal  to  a  premature. 

Prematures  need  a  good  deal  of  water  inside,  but  none  outside. 
The  water  should  be  given  between  each  feeding,  the  amount 
being  the  same  amount  as  the  feeding. 

What  is  the  prognosis  for  premature  babies?  These  three 
facts  were  brought  out  from  an  analysis  of  125  cases  by  Dr. 
Maynard  Ladd :  The  mortality  was  65  percent  in  babies  weigh- 
ing under  four  and  one-half  pounds  at  birth.  A  baby  under 
this  weight  is  very  likely  to  die.  Second,  no  child  weighing 
less  than  two  and  one-haK  pounds  lived.  Third,  no  child  at  the 
sixth  month  of  gestation  lived. 

A  premature  baby  needs  an  extreme  amount  of  painstaking 
care.  Nothing  in  the  world  is  harder  to  take  care  of,  both  as  to 
its  feeding  and  as  to  its  general  care. 


LECTURE  IV 

DIFFICULT  FEEDING  CASES— THE  VARIOUS  TYPES  OF 
INDIGESTION— THE    STOOLS    IN    INFANCY- 
CONSTIPATION 

I  am  going  to  talk  today  about  the  feeding  of  abnormal  babies 
and  the  different  types  of  indigestion  and  of  nutritional  dis- 
turbances. 

There  is  no  absolutely  satisfactory  classification  of  digestive 
disturbances;  the  classification  which  I  am  going  to  give  you 
has  its  faults,  but  it  is,  in  the  main,  fairly  satisfactory.  The 
basis  of  it  is  this :  We  look  upon  the  baby's  food  as  being  com- 
posed of  elements,  of  which  we  have  already  spoken  many  tim£s, 
and  we  look  upon  the  disturbances  of  digestion  and  nutrition  as 
being  for  the  most  part  due  to  an  excess  or  deficit  in  the  food  of  one 
or  more  of  the  food  elements,  or  faulty  digestion  or  absorption  of 
one  or  more  of  these  elements,  when  they  may  perhaps  be  present 
in  normal  amounts  in  the  food.  The  food  as  a  whole,  of  course, 
has  also  to  be  considered,  as  does  the  proper  relationship  of  the 
food  elements  to  each  other;  that  is,  the  baby  must  have  a  well- 
balanced  food,  and  one  element  must  not  be  present  in  it  in  great 
excess,  as  compared  to  the  others. 

The  classification  is  as  follows: 

1.  Too  little  food — starvation. 

2,  Disturbances  of  digestion. 

a.  Too  much  food  as  a  whole. 

&.  Fat  indigestion. 

c.  Sugar  indigestion. 

d.  Protein  indigestion. 

e.  Starch  indigestion. 

Too  Little  Food,  or  Starvation. — First  of  all,  let  us  take  up 
class  1.  There  are  a  great  many  babies  who  have  not  had 
enough  to  eat,  and  that  is  the  cause  of  their  troubles.     Some  of 

59 


60  INFANT   FEEDING    (BOSTON  METHODS) 

these  babies,  if  the  starvation  has  continued  long  enough,  may 
present  the  typical  picture  of  the  so-called  "marasmus"  or 
"infantile  atrophy."  These  are  likely  to  be  babies  who  have 
been  fed  on  condensed  milk  or  on  one  of  the  proprietary  foods, 
or  on  milk  diluted  too  much,  and  have  been  shifted  about  from 
one  food  to  another — never  doing  well  on  any  of  them.  In 
consequence,  the  baby  is  starved ;  its  digestion  is  also  extremely 
weak.  This  is  a  common  type  of  case.  In  such  cases  first 
examine  the  baby  carefully  to  exclude  wasting  diseases,  like 
tuberculosis  and  syphilis,  in  order  to  make  sure  that  the  baby  is 
suffering  from  malnutrition  alone.  One  should  always  be 
suspicious  of  tuberculosis  or  syphilis  in  small,  poorly  nourished 
babies.  Go  into  the  previous  feeding  history  carefully,  and 
see  what  the  child  is  taking  at  the  present  time  and  how  much 
it  is  getting  in  calories.  If  the  calories  taken  are  below  par, 
give  more  to  eat.  That  is  easy  to  say,  but  hard  to  do,  be- 
cause any  baby  fed  for  a  long  time  on  an  insufficient  amount 
of  food  has  a  very  weak  digestion,  and  it  is  necessary  to 
start  with  a  weak  food  and  gradually  increase  it  in  dealing  with 
these  babies.  The  fat  percentage  especially  must  be  raised 
slowly  in  feeding  babies  of  this  type,  because  they  usually  have 
very  poor  digestions  for  fat.  Sometimes  small  doses  of  nux 
vomica  are  of  value  in  these  cases,  but  aside  from  this,  drugs  are 
of  little  aid.  The  stools  should  be  examined  to  be  sure  that 
there  is  no  indigestion  of  any  particular  food  element  in  addi- 
tion to  the  starvation.  I  will  speak  of  the  technic  later.  The 
examination  of  the  stools  is  not  the  whole  story  in  infant  feed- 
ing, by  any  means,  but  it  is  extremely  important  and  desirable 
to  make  frequent  examinations  of  the  stools  of  any  baby  who  is 
not  gaining  properly  in  order  to  find  out  how  well  the  different 
food  elements  are  being  absorbed.  This  is  one  of  the  funda- 
mentals of  the  Boston  methods  of  infant  feeding:  In  order  to 
feed  any  bahy  intelligently  the  physician  must  regulate  the  food 
supply  by  the  waste, — that  is,  the  unabsorbed  portion  of  the  food, — 
and  the  food  must  be  of  sux^h  a  nature  that  there  is  not  too  much 
waste.  Find  out  by  careful  stool  examination  what  element  or 
elements  of  the  food  the  baby  is  not  digesting  or  absorbing,  and  then 
regulate  the  food  supply  in  accordance  with  this. 

Let  us  consider  now  the  disturbances  of  digestion. 


DIFFICULT   FEEDING   CASES  61 


DISTURBANCES  OF  DIGESTION 

Too  Much  Food. — A  great  many  babies  may  be  getting  too 
much  at  a  feeding  or  may  be  fed  too  often,  or  the  food  may  be 
too  rich.  As  a  consequence,  the  digestion  is  upset.  This  type 
of  disturbance  may  be  acute  or  chronic,  and  is  manifested  by 
failure  to  gain,  fussiness,  cohc,  vomiting,  and  possibly  by  diar- 
rhea. These  cases  are  usually  not  difficult  to  deal  with.  It  is 
generally  wise  to  clean  out  the  baby  at  once  with  castor  oil  or 
calomel,  then  starve  it  for  twenty-four  hours  on  weak  barley 
water  or  water.  Start  in  then  with  a  weak  food  and  gradually 
build  it  up  to  the  limit  of  the  baby's  digestion,  watching  the 
stools  carefully  to  see  that  this  limit  is  not  exceeded. 

Acute  Fat  Indigestion. — The  symptoms  of  acute  fat  indiges- 
tion from  too  much  fat  in  the  food  are  very  much  the  same  as 
the  symptoms  from  too  much  food.  The  vomitus  may  be 
creamy,  and  the  stools  are  likely  to  show  a  great  many  small 
white  fat  curds,  or  they  may  rarely  be  oily.  First  examine  the 
stools  to  be  sure  that  it  is  an  upset  from  fat,  and  inquire  into 
the  diet.  If  a  large  excess  of  fat  is  found  in  the  stools,  cut 
down  the  fat  in  the  diet,  or  cut  it  out  entirely  for  a  few  days, 
feeding  the  baby  on  some  modification  of  skimmed  milk  without 
any  fat,  and  increasing  the  fat  one-half  percent  at  a  time  until 
the  point  is  reached  where  the  baby  is  getting  enough  fat  and 
not  too  much. 

Chronic  Fat  Indigestion. — Babies  have  more  trouble  from 
chronic  fat  indigestion  than  from  any  other  form  of  chronic 
indigestion.  It  is  really  not  fat  indigestion,  because  the  fat  is 
spUt  into  glycerin  and  fatty  acids  perfectly,  in  most  cases,  but 
the  soaps  which  are  formed  are  not  absorbed.  The  difficulty  is 
thus  in  the  proper  absorption  of  the  fat  after  it  has  been  digested. 
Clinically,  chronic  fat  indigestion  is  likely  to  be  seen  in  babies 
who  have  been  fed  on  high  percentages  of  fat  for  a  long  period 
of  time,  or  in  babies  who  have  been  fed  on  foods  containing  a 
large  amount  of  carbohydrate  and  very  little  fat — especially  the 
proprietary  foods.  The  exact  etiology  and  the  chemistry  of  the 
condition  are  rather  obscure.  It  is  known  that  cow's  milk  con- 
tains a  much  higher  percentage  of  volatile  fatty  acids  than  hu- 
man milk  does,  and  also  a  much  higher  percentage  of  calcium, 


62  INFANT  FEEDING    (BOSTON  METHODS) 

which  combines  in  the  intestine  with  these  volatile  fatty  acids 
to  form  insoluble  calcium  soaps  which  cannot  be  absorbed.  I 
beUeve  that  many  cases  of  fat  indigestion  are  due  to  this,  and 
this  is  why  so  many  babies  with  fat  indigestion  will  do  well  on 
breast  milk,  which  may  contain  actually  two  or  three  times  as 
much  fat  as  the  cow's  milk  modification  which  they  have  been 
unable  to  handle. 

The  symptoms  of  fat  indigestion  are  that  a  baby  does  not  gain 
in  weight,  is  fussy  and  miserable,  may  have  rickets,  may  vomit 
a  little,  and  may  have  diarrhea  or  chronic  constipation  or  an 
alternation  of  the  two.  There  may  be  the  so-called  "soap" 
stools:  hard,  light  colored,  crumbly,  consisting'  of  insoluble 
soaps.  The  stools  may  again  resemble  scrambled  eggs,  with 
many  small  curds,  or  they  may  occasionally  look  normal,  but 
show  a  large  excess  of  fat  none  the  less.  The  way  to  diagnose  a 
fat  intolerance  is  to  examine  the  stools  microscopically  and  see 
if  there  is  an  excess  of  fat  present.  The  treatment  is  difficult; 
these  are  the  hardest  cases  that  one  has  to  deal  with  in  infant 
feeding.  Some  of  them  may  present  the  picture  of  "maras- 
mus." 

For  purposes  of  treatment  the  cases  of  fat  intolerance  may  be 
divided  into  two  groups : 

1.  The  Type  With  Dry,  Constipated,  "  Soapy  ^'  Stools. — In  this 
type  the  stools  are  as  above  described,  and  are  usually  neutral 
or  mildly  acid  or  alkaline  in  reaction.  The  treatment  is  to  cut 
the  fat  entirely  out  of  the  diet  for  a  while,  and  make  up  for  this 
by  adding  more  sugar  and  protein.  Care  must  be  taken,  how- 
ever, not  to  add  enough  sugar  or  protein  to  give  the  baby  a 
sugar  or  protein  indigestion.  This  type  of  case  usually  does 
well  on  a  high  sugar  diet,  however.  After  a  few  days  of  a  fat- 
free  diet  fat  can  gradually  be  added  to  the  diet  again  up  to  the 
limit  of  the  baby's  tolerance,  watching  the  stools  carefully  for 
fat  to  determine  what  this  tolerance  is.  Usually  it  is  well  not 
to  increase  the  fat  in  the  diet  more  than  one-half  percent  at  a 
time.  Sometimes  these  babies  have  to  be  kept  on  a  low  fat 
percentage  for  a  long,  long  time,  and  the  condition  requires  ex- 
treme patience  on  the  part  of  both  mother  and  doctor.  It  is 
not  a  question  of  a  few  days  or  a  few  weeks,  but  a  question  of 
months  during  which  the  baby's  diet  must  be  regulated  with  the 


DIFFICULT   FEEDING   CASES  63 

utmost  care.  Sometimes  it  is  valuable  to  add  two  or  three 
teaspoonfuls  of  olive  oil  a  day  to  the  baby's  diet,  as  some  of 
these  babies  are  able  to  absorb  a  vegetable  fat  when  they  cannot 
absorb  the  fat  in  cow's  milk.  The  method  of  homogenization 
of  olive  oil  and  other  vegetable  fats  with  skimmed  milk  is  also  of 
value  in  treating  these  cases,  but,  of  course,  is  not  applicable 
outside  of  two  or  three  large  cities  where  the  homogenized  milk 
may  be  obtained.  /  believe  it  is  a  mistake  to  add  any  lime-water 
to  a  mixture  fed  to  a  haby  with  fat  intolerance,  as  this  favors  the 
formation  of  insoluble  calcium  soaps.  If  an  alkali  is  to  be  used 
in  these  cases,  sodium  citrate  is  the  one  to  use.  I  nearly  forgot 
to  mention  one  of  the  most  important  points :  It  is  always  well 
to  get  a  wet-nurse,  if  possible,  for  a  baby  with  severe  chronic 
indigestion,-  whether  it  be  of  fat  or  of  any  one  of  the  other  food 
elements. 

2.  The  Type  With  "  Scrambled-egg"  Stools. — In  this  type  of 
chronic  fat  indigestion  the  stools  are  loose,  rather  frequent,  and 
yellow  or  yellowish  green  in  color.  They  contain  many  small 
white  fat  curds,  smell  acid,  and  are  strongly  add  in  reaction. 
Microscopically  they  show  a  large  excess  of  fat.  The  trouble 
in  these  cases  is  due  to  a  combination  of  fat  and  of  sugar  in- 
digestion, and  sometimes  it  is  hard  to  tell  which  predominates. 
What  happens  chemically  is  this:  the  fats  and  the  sugars  both 
break  down  to  form  volatile  fatty  acids,  and  these  are  present 
in  the  stools,  partly  free  and  partly  combined  with  alkali  to  form 
soaps.  It  is  uncertain  which  of  these  processes  is  primary — 
the  breaking  down  of  the  fat  or  of  the  sugar.  The  absorption  of 
the  fat  is  hindered  in  a  number  of  ways  in  these  cases. 

Insoluble  soaps  are  formed  from  the  volatile  fatty  acids  and 
calcium  present  in  the  milk  to  start  with,  and  also  from  the 
higher  volatile  fatty  acids  which  have  been  formed  in  the  in- 
testine. 

The  reaction  of  the  intestine  is  very  strongly  acid,  due  to  the 
various  acids  present  from  abnormal  fat  and  sugar  decom- 
position. Bile  is  a  very  unstable  substance,  especially  in  an  acid 
medium.  It  may  be  possible  that  the  bile  is  decomposed  in  the 
strongly  acid  intestine,  and  is  thus  rendered  useless  in  the  emul- 
sification  of  the  fats  which  is  necessary  for  their  proper  absorp- 
tion. 


64  INFANT   FEEDING    (BOSTON   METHODS) 

It  is  a  chemical  fact  that  it  is  impossible  for  a  good  emulsion 
to  be  formed  in  a  strongly  acid  medium.  It  is  possible  then  that 
the  proper  emulsification  of  the  fats  is  hindered  in  this  way  also. 

This  condition  has  always  been  an  extremely  interesting  one 
to  me,  and  I  must  confess  that  in  very  many  cases  it  is  extremely 
difficult  and  sometimes  impossible  to  tell  just  how  much  of  the 
trouble  is  due  to  fat  and  how  much  to  sugar.  I  call  the  condi- 
tion a  fat  indigestion,  however,  because  the  most  striking  thing 
about  it  is  the  poor  fat  absorption.  The  treatment  must  be 
somewhat  different  from  that  of  the  other  type  of  fat  tolerance, 
because  here  there  is,  in  addition  to  the  low  fat  tolerance,  a  low 
sugar  tolerance.  We  must,  therefore,  feed  a  food  low  in.  fat  and 
sugar,  and  high  in  protein.  In  the  severe  cases  it  is  well  to  cut 
the  fat  entirely  from  the  diet;  in  the  milder  cases  it  can  be 
halved.  The  sugar  should  be  considerably  reduced,  usually  to 
3  or  4  percent  for  a  while,  and  then  increased  again  up  to  the 
hmit  of  tolerance  as  the  baby  improves.  The  protein  should  be 
as  high  as  the  baby  will  stand.  Usually  3  percent  of  protein 
will  be  handled  fairly  well  by  most  babies  over  two  or  three 
months  old  when  they  have  this  type  of  indigestion.  There  are 
two  reasons  for  feeding  a  high  protein  percentage:  first,  because 
the  digestion  for  protein  is  usually  good;  second,  because  the 
digestion  for  fat  and  sugar  will  be  improved  if  the  reaction  of 
the  intestinal  contents  can  be  made  less  acid,  which  is  what 
happens  when  a  high  protein  milk  is  fed. 

The  protein  must  be  given  in  such  a  form  that  it  can  be  easily 
handled.  If  an  ordinary  milk  mixture  is  used,  it  is  well  to  add 
two  grains  of  sodium  citrate  for  each  ounce  of  milk  to  prevent 
the  formation  of  tough  casein  curds  in  the  stomach. 

"  Eiweiss  "  milk  is  valuable  in  treating  some  of  these  cases,  and 
if  this  is  used,  the  protein  is,  of  course,  in  a  finely  divided  pre- 
cipitated form  which  is  easily  digested. 

I  have  never  been  satisfied  with  the  treatment  of  fat  intoler- 
ance: we  really  know  so  little  about  its  exact  chemistry  and 
etiology.  There  are  so  many  obscure  factors  that  enter  into  it, 
concerning  which  the  state  of  our  knowledge  is  at  present  so  im- 
perfect, that  our  results  are  by  no  means  as  good  as  they  might  be. 

Acute  Sugar  Indigestion. — Most  babies  w411  get  into  trouble 
if  they  are  taking  over  7  percent  of  sugar  in  the  diet.     The 


DIFFICULT   FEEDING   CASES  65 

symptoms  of  sugar  indigestion  are  vomiting  of  rather  thin,  sour 
material,  a  good  deal  of  colic  and  gas,  and  the  passage  of  fre- 
quent, loose,  green,  acid-smelling  movements.  These  move- 
ments, and  the  whole  disturbance,  are  due  to  fermentation  of 
sugar  in  the  intestine,  with  the  consequent  formation  of  volatile 
acids,  such  as  acetic  and  butyric,  irritating  the  intestine  and  thus 
causing  increased  peristalsis.  Sugar  indigestion  is  likely  to  be 
more  severe  than  any  of  the  other  forms  of  acute  indigestion. 
Most  of  the  cases  will  do  fairly  well  with  proper  treatment, 
which  is  to  starve  the  baby  for  twenty-four  hours,  starting  the 
subsequent  feeding  with  a  food  very  low  in  sugar.  No  cantor 
oil  is  necessary,  for  the  baby  has  cleaned  itself  out  by  the  diar- 
rhea it  is  having.  After  the  starvation,  go  back  to  a  diet  with  as 
little  sugar  in  it  as  possible.  ''Eiweiss"  milk  fulfils  these  in- 
dications. It  is  always  best  to  keep  the  sugar  percentage  low 
for  a  few  days,  and  then  very  gradually  add  the  sugar  again, 
The  sugar  which  is  usually  best  to  use  in  a  case  of  this  type  is  a 
malt-sugar  preparation,  because  the  malt-sugars  have  less  ten- 
dency to  ferment  than  lactose  or  sucrose,  and  are  absorbed  more 
quickly. 

There  are  no  hard-and-fast  lines  to  be  drawn  between  sugar 
indigestion  and  what  I  call  fermentative  diarrhea,  because  in 
most  cases  of  sugar  indigestion  there  is  likely  to  be  a  good  deal 
of  fermentation.  We  shall  discuss  this  fermentative  diarrhea 
at  the  next  lecture. 

Chronic  Sugar  Indigestion. — Chronic  sugar  indigestion  is  not 
so  common  as  chronic  fat  indigestion.  The  symptoms  are  very 
much  the  same  as  in  acute  sugar  indigestion:  the  passage  of 
loose,  watery,  green,  acid-smelling  stools.  The  baby's  buttocks 
are  likely  to  be  red  and  irritated  from  the  acids  in  these  stools. 
When  stools  of  this  type  are  present,  it  is  certain  that  there  is 
fermentation  of  sugar  in  the  intestine,  and  the  indications  are 
to  feed  a  low  sugar  percentage.  These  cases  are  not  so  chronic 
as  the  fat  cases.  Generally,  after  giving  a  low  sugar  percentage 
for  a  few  weeks,  in  combination  with  a  high  protein,  the  sugar 
tolerance  will  be  so  increased  that  a  reasonable  sugar  percentage 
can  be  given  again. 

Acute  Protein  Indigestion. — Acute  indigestion  from  protein  is 
conmaon.  It  shows  itself  by  the  vomiting  of  large,  tough  curds, 
6 


66  INFANT   FEEDING    (BOSTON  METHODS) 

due  to  coagulation  of  the  casein  in  the  stomach.  Besides  this, 
there  is  likely  to  be  a  good  deal  of  colic  and  abdominal  pain, 
with  or  without  diarrhea.  There  are  very  likely  to  be  hard, 
large  curds  of  casein  in  the  stools.  The  stools  may  be  of  two 
sorts — yellowish  or  brownish,  with  these  large  curds;  or  of  a 
brown  color,  loose,  with  a  strongly  musty,  foul  smell,  with  no 
curds.  The  treatriient  of  protein  indigestion  is  to  cut  down  the 
protein  in  the  milk.  Usually  in  the  type  where  the  stools  are 
yellow,  with  the  curds  present,  this  is  sufficient  to  cure  the 
trouble — to  starve  the  baby  for  twenty-four  hours  and  cut  down 
the  protein  in  the  subsequent  diet.  In  the  other  type  the  con- 
dition is  a  good  deal  more  serious,  and  it  is  usually  best  to  starve 
the  baby  a  little  longer,  giving  it  a  lactose  solution  of  6  or  7 
percent  with  starch  to  0.75  or  1  percent.  In  the  subsequent 
feeding  the  sugar  in  the  diet  should  be  kept  relatively  consider- 
ably higher  than  the  protein,  as  there  is  alkaline  decomposition 
going  on  in  the  intestine  and  it  is  desirable  to  change  the  reaction 
of  the  intestine  from  alkaline  to  acid.  This  is  usually  the  worst 
type.  If  tough  curds  are  being  vomited  or  passed  in  the  stools, 
some  of  the  methods  which  I  have  mentioned  before  of  making 
the  protein  easily  digested  in  the  stomach  maj'-  be  used.  This 
condition  of  protein  indigestion  usually  clears  up  very  well. 
Most  babies  will  get  over  it  in  a  few  days  with  the  proper  treat- 
ment. 

Chronic  Protein  Indigestion. — Chronic  protein  indigestion  is 
not  very  common,  and  when  it  is  seen,  it  is  usually  accompanied 
by  the  loose,  brown,  musty-smelling  stools.  The  treatment  is 
to  feed  a  food  low  in  protein  and  high  in  carbohydrate. 

Starch  Indigestion. — I  am  not  going  to  speak  of  acute  starch 
indigestion  because  it  is  rare,  and  chronic  starch  indigestion  is 
the  more  important.  Chronic  starch  indigestion  is  often  seen, 
especially  in  older  children.  In  small  babies  it  may  occur  when 
over  1  to  1.5  percent  of  starch  is  being  fed  in  the  diet.  The 
symptoms  are  very  much  the  same  as  those  of  fat  indigestion. 
The  stools  are  different;  they  may  be  brown  and  gelatinous, 
with  many  small,  jelly-like  particles  scattered  through  them, 
or  they  may  more  rarely  be  loose  and  green,  like  the  stools  of 
sugar  indigestion.  The  treatment,  of  course,  is  to  cut  out  the 
starch  and  make  up  the  deficiency  with  the  other  food  elements. 


DIFFICULT  FEEDING   CASES  67 

Of  course,  this  classification  we  have  been  discussing  is  not 
at  all  hard  and  fast,  because  when  one  type  of  indigestion  is 
present,  there  may  be  also  present  some  other  type.  Generally 
one  type  predominates,  however,  but  the  digestion  may  be  also 
weakened  for  some  of  the  other  food  elements. 

You  will  notice  that  in  discussing  these  nutritional  disturb- 
ances I  have  not  mentioned  the  salts.  These  are,  of  course,  of 
very  great  importance,  but  we  know  so  little  about  the  metab- 
olism of  the  salts,  and  the  whole  question  of  their  role  in  nutri- 
tion is  so  complicated,  that,  with  the  present  state  of  our  knowl- 
edge, we  can  take  them  into  very  little  consideration  in  practical 
feeding. 

Now  I  want  to  talk  about  chronic  fat  and  starch  indigestion 
in  older  children.  This  is  a  common  condition.  I  have  seen  a 
number  of  cases  of  this  type  since  I  have  been  here.  The  usual 
story  is  that  there  has  been  a  good  deal  of  trouble  with  the  child's 
digestion  from  the  first,  and  the  trouble  does  not  seem  to  im- 
prove much  as  the  child  grows  older.  These  children  may  be 
anywhere  from  two  to  eight  or  ten  years  of  age,  and  I  have  seen 
a  typical  case  of  "marasmus"  from  chronic  starch  indigestion 
in  a  child  of  twelve.  These  children  are  much  under  weight, 
and  sometimes  may  be  so  much  emaciated  that  they  are  little 
more  than  skin  and  bones.  They  are  underdeveloped  in  every 
way,  fretful  and  irritable,  and,  on  the  whole,  pretty  miserable- 
looking  specimens. 

The  abdomen  is  usually  considerably  distended,  and  the  chest 
apparently  very  small  in  relation  to  the  abdomen.  Rickets 
may  or  may  not  be  present,  and  there  is  usually  considerable 
anemia.  There  is  no  use  experimenting  with  different  foods  in 
these  cases  until  the  cause  of  the  child's  indigestion  has  been  dis- 
covered. It  is  impossible  to  feed  these  children  intelligently  until 
the  stools  have  been  examined  to  see  what  the  child  is  digesting  and 
what  it  is  not  digesting,  and  by  this  make  a  diagnosis  of  the  type  of 
indigestion  and  regulate  the  food  supply  accordingly. 

Fat  Intolerance. — In  feeding  these  cases  the  utmost  care  is 
necessary,  and  it  is  usually  very  hard  to  manage  them  when  the 
children  stay  at  home,  because  the  parents  are  likely  to  give 
them  anything  they  want  to  eat.  Generally  the  digestion  for 
every  food  element  is  weak,  but  especially  so  for  fat.     For  these 


68  INFANT  FEEDING    (BOSTON  METHODS) 

cases  write  out  an  absolutely  iron-clad  diet  list,  showing  just 
what  the  child  is  to  eat  in  the  twenty-four  hours.  Most  cases  of 
this  sort  must  be  on  a  carefully  regulated  diet  for  a  year  or 
two  years  before  the  digestion  returns  to  anything  like  the 
normal.  Sometimes  if  a  child  gets  to  the  table  and  eats  a  piece 
of  butter  the  size  of  a  pea  it  will  be  completely  upset  again. 
It  is  necessary  to  keep  the  child  on  a  fat-free  or  a  very  low  fat 
diet,  the  diet  being  made  up  mostly  of  starchy  and  protein  foods. 
As  to  drugs,  it  is  usually  of  a  good  deal  of  advantage  to  get  these 
children  cleaned  out  with  castor  oil  once  a  week,  as  the  intes- 
tines may  be  sluggish.  Nux  vomica  is  also  a  very  good  drug 
to  give.  For  anemia,  of  course,  iron  is  indicated.  Needless  to 
say,  have  the  child  get  all  the  fresh  air  possible  and  live  in  a  sen- 
sible and  hygienic  manner.  Excellent  results  can  be  obtained 
with  these  cases  if  the  family  is  intelligent  and  will  carry  out  di- 
rections; but  if  one  is  deahng  with  an  ignorant  and  stupid 
mother  who  will  not  carry  out  all  directions  absolutely,  it  is 
hopeless  to  expect  to  get  good  results. 

You  can,  perhaps,  get  a  better  idea  of  cases  of  this  sort  by  a 
discussion  of  a  concrete  case.  This  history  is  of  a  girl  of  five 
years  who  entered  the  Children's  Hospital  April  14,  1916.  It 
is  a  very  typical  case  of  fat  intolerance. 

History 

Past  History. — Normal  delivery.  Breast  fed  for  five  months. 
Birth  weight,  six  pounds.  After  five  months  breast  milk  gave 
out  and  the  child  was  put  on  Eskay's  Food  for  a  month.  After 
this  she  was  fed  on  barley  gruel  and  whole  milk.  She  did  fairly 
well  up  to  a  year  ago. 

Present  Illness. — About  a  year  ago  she  began  to  have  diar- 
rhea. This  diarrhea  would  last  for  about  a  week,  then  she 
would  apparently  be  perfectly  well  for  a  while,  when  the  diar- 
rhea would  return.  During  the  periods  of  diarrhea  she  would 
have  six  to  eight  loose,  light-colored  stools  in  twenty-four  hours, 
without  mucus  or  blood.  Most  of  the  time  she  has  been  kept 
on  a  fairly  careful  diet,  except  that  she  gets  off  with  the  other 
children  occasionally  and  eats  a  good  deal  of  candy,  etc.  At 
these  times  her  digestion  appears  to  be  especially  upset,  and  she 
vomits  and  the  diarrhea  becomes  more  marked.     No  vomiting 


•     DIFFICULT   FEEDING   CASES  69 

at  any  other  time.  For  the  last  week  she  has  been  so  weak  she 
has  had  to  stay  in  bed,  and  has  been  on  a  diet  of  bread  and  milk, 
beef-juice,  port  wine,  and  albumin  water. 

Weight  one  year  ago,  31  pounds;  now,  183^  pounds. 

Short  Summary  of  Physical  Examination. — Very  poorly  de- 
veloped and  nourished.  Pale.  Skin  dry  and  loose.  Glands, 
moderate  general  enlargement.  Abdomen  very  large,  tym- 
panitic save  in  flanks,  where  there  is  shifting  dulness.  No  fluid 
wave.     No  masses,  spasm,  or  tenderness. 

Stool  brown,  hard,  smooth,  alkaline ;  no  mucus.  Microscopi- 
cally shows  a  large  excess  of  neutral  fat  and  soaps.     No  starch. 

This  girl  was  treated  as  follows :  She  was  at  first  kept  in  bed, 
as  she  was  too  weak  to  stand.     These  drugs  were  given: 

Tincture  nux  vomica 5  minims  three  times  daily 

Saccharated  oxid  of  iron  ...   5  grains        "        "        " 

Castor  oil  was  needed  about  once  a  week,  as  she  had  a  good 
deal  of  distention  at  times,  and  a  thorough  cleaning  out  oc- 
casionally seemed  to  help  her  a  good  deal. 

The  diet  was  scanty  at  first,  but  was  gradually  increased  as 
she  grew  stronger. 

April  15th  she  took: 

Zwieback 3  slices 

Beef-juice 2  ounces 

Cereal  (farina) 3  tablespoons 

Fat-free  milk 24  ounces 

She  improved  rapidly,  and  was  soon  strong  enough  to  be  up 
and  around  the  ward.  The  stools  varied  a  good  deal.  Some- 
times they  were  hard  and  constipated,  sometimes  they  looked 
normal,  and  sometimes  they  were  very  loose  and  foul.  The  fat 
was  never  in  excess  while  she  was  on  the  low  fat  diet. 

May  9th  she  was  taking: 

Cereal  (farina) 1  tablespoon 

Bread  (stale) 2  slices 

Zwieback 3     " 

Beef-juice 3  ounces 

Chopped  meat 1  oimce 

One  egg 

Juice  of  half  an  orange 

Apple-sauce 2  tablespoons 

Fat-free  milk 24  ounces 


70  INFANT   FEEDING    (BOSTON  METHODS) 

She  was  kept  on  practically  this  same  diet  until  she  was  dis' 
charged,  very  greatly  improved. 

Her  weight  at  entrance  was  18  pounds  4  ounces. 

Her  weight  at  discharge  was  24  pounds  8  ounces. 

Average  gain  per  week,  9  ounces. 

I  have  not  happened  to  see  this  particular  girl  since  she  left 
the  hospital,  but  it  is  certain  that  if  her  mother  has  not  dieted 
her  strictly  she  is  in  just  as  bad  condition  as  she  was  before  she 
entered  the  hospital.  If  her  mother  takes  pains  to  diet  her 
carefully,  she  will  probably  get  along  very  well. 

Starch  Intolerance. — The  symptoms  of  starch  indigestion  are 
very  much  the  same  as  those  of  fat  indigestion.  The  stools  are 
different,  being  brown  and  loose,  with  a  great  deal  of  jelly-like 
material.  There  is  also  likely  to  be  a  great  deal  of  cellulose  in 
the  stools.  Sometimes  the  stools  of  cases  of  starch  indigestion 
may  be  green  and  watery,  and  sometimes  may  be  extremely 
foul.  If  the  diet  of  these  children  is  investigated,  it  will  be  found 
that  they  eat  a  tremendous  amount  of  starch  in  the  form  of  hot 
bread,  potatoes,  etc.,  and  also  a  good  many  green  vegetables 
and  fruits.  The  thing  to  do  in  these  cases  is  to  cut  out  the 
starch  as  much  as  possible.  Of  course  it  cannot  be  cut  out  en- 
tirely, because  children  of  this  age  depend  so  much  upon  cereals. 
However,  it  can  be  cut  down  considerably,  and  coarse  vege- 
tables and  fruits  can  be  removed  from  the  diet.  The  starch  that 
is  taken  should  be  very  thoroughly  cooked.  Any  cereals  these 
children  take  should  be  cooked  overnight.  The  diet  list  should 
be  written  down.  It  can  be  practically  the  same  from  day  to 
day,  for  most  children  do  not  at  all  mind  a  monotonous  diet. 
The  essential  things  are  to  feed  a  low  starch,  thoroughly  cooked 
diet,  cut  out  the  fruit  and  coarse  vegetables,  and  have  all  the 
food  the  child  takes  in  as  finely  divided  a  form  as  possible. 

THE  STOOLS  IN  INFANCY 

There  are  a  few  points  I  want  to  mention  about  the  stools  in 
infancy.  If  any  of  you  are  interested,  you  will  find  the  subject 
discussed  more  fully  in  Dr.  Morse's  "Case  Histories  in  Pedi- 
atrics," which  I  have  recommended  to  you  before. 

The  examination  of  the  stools  is  of  very  great  importance, 


THE   STOOLS   IN   INFANCY  71 

both  macroscopic  and  microscopic,  and  usually  altogether  too 
little  attention  is  paid  to  it.  It  is  perfectly  obvious  to  any  one 
that  it  is  a  rational  and  sensible  thing,  when  dealing  with  a  baby 
who  has  indigestion,  to  examine  its  stools  carefully  and  get  as 
much  information  as  possible  from  this  source.  However,  stool 
examination  is  not  the  whole  story  in  infant  feeding  by  any 
means,  and  the  weight  and  general  condition  of  the  baby  must 
also  be  considered.  Stool  examination  is  perhaps  the  most  im- 
portant guide  we  have,  however,  and  if  one  is  expert  at  it,  a 
great  deal  may  be  learned  about  what  is  going  on  in  the  baby'3 
intestine,  by  a  careful  examination  of  the  discharges. 

The  reaction  of  the  stools  is  sometimes  of  considerable  im- 
portance. In  the  infant's  intestine  two  processes  are  continu- 
ally working  against  and  counterbalancing  each  other:  decom- 
position of  fat  and  carbohydrates,  with  acid  end-products,  and 
decomposition  of  protein,  with  alkaline  end-products.  These 
two  processes,  under  normal  conditions,  just  about  balance 
each  other,  so  that  a  normal  stool  is  either  slightly  alkaUne, 
neutral,  or  slightly  acid  in  its  reaction.  If  the  intestinal  con- 
tents are  too  strongly  acid  or  too  strongly  alkahne,  trouble 
usually  results,  due  to  the  irritant  action  in  the  intestine  of  the 
acid  or  alkaline  end-products, 

Some  of  the  various  types  of  abnormal  stools  seen  are  as 
follows : 

1.  Fat  Indigestion. — The  stools  in  this  condition  may  be  of 
a  number  of  types: 

(1)  The  ''scrambled-egg"  stool,  acid  smelling,  loose,  and  with 
many  soft,  white  fat  curds  scattered  through  it.  With  stools 
of  this  type  there  is  also  probably  some  sugar  indigestion  in 
addition  to  the  fat. 

(2)  The  "soap  stool,"  usually  a  hard,  light-colored,  rather 
dry  and  crumbly  stool,  sometimes  almost  white.  Typical  soap 
stools  are  made  up  very  largely  of  insoluble  calcium  and  mag- 
nesiimi  soaps. 

(3)  The  oily  stool.  Sometimes  in  cases  of  fat  indigestion  the 
stool  may  be  a  light  yellowish-brown  color  and  very  oily.  These 
stools  are  not  particularly  common, 

(4)  Some  stools  which  contain  a  large  excess  of  fat  may  look 
perfectly  normal  macroscopically,  but  when  examined  under 


72  INFANT   FEEDING    (BOSTON   METHODS) 

the  microscope  will  be  seen  to  contain  a  large  excess  of  fat. 
These  stools  are  usually  of  a  salve-like  consistence. 

2.  Sugar  Indigestion. — The  stools  of  sugar  indigestion  are 
always  strongly  acid  in  reaction.  They  are  usually  loose, 
green,  strongly  acid  smelling,  and  may  contain  fat  curds,  due 
to  the  fact  that  the  stool  has  been  hurried  through  the  intestine 
so  fast  that  the  fat  has  not  had  time  to  be  absorbed.  The  stools 
of  mild  sugar  indigestion  may  sometimes  closely  resemble  the 
"  scrambled-egg  "  stools  of  fat  indigestion  previously  described. 

3.  Protein  Indigestion. — The  stools  of  protein  indigestion 
may  be  of  two  types.  The  first  type  is  usually  yellowish  or 
hght  brown,  and  contains  casein  curds,  which  are  smooth,  tough, 
white,  bean-shaped  masses  of  coagulated  casein.  The  second 
type  is  brown,  loose,  foul,  strongly  a&ahne  in  reaction,  and  may 
be  frothy  or  bubbly.  This  tjq^e  of  stool  indicates  that  there  is 
considerable  decomposition  of  protein  going  on  in  the  intestine. 

4.  Starch  Indigestion. — The  stools  of  starch  indigestion  are 
usually  loose,  foul  smelHng,  rarely  smooth  or  homogeneous,  are 
brown  in  color,  and  are  likely  to  contain  small,  brown,  mucilagin- 
ous masses  of  partly  digested  starch,  together  with  a  good  many 
coarse  cellulose  remains,  such  as  seeds,  pulp  of  fruit,  etc.  Oc- 
casionally the  stools  from  cases  of  starch  indigestion  may  be 
dry  and  crumbly  or  more  rarely  green  and  watery. 

By  all  means  the  most  common  type  is  the  one  first  described. 

Microscopic  Examination  of  the  Stools. — The  microscopic 
examination  of  the  stools  is  important.  By  microchemical 
methods  we  test  for  fat  or  starch. 

The  technic  of  the  fat  test  is  as  follows: 

Place  a  small  portion  of  the  stool  on  a  glass  slide,  add  a  drop 
or  two  of  glacial  acetic  acid  and  a  drop  or  two  of  a  saturated 
alcoholic  solution  of  Sudan  III  stain.  Rub  up  the  stool,  acid, 
and  stain  together,  and  heat  gently  for  a  moment  over  an  al- 
cohol lamp.  Examine  with  the  low  power  of  the  microscope; 
the  fat  shows  itself  as  small,  orange-red  globules.  Nearly  all 
stools  contain  a  fair  amount  of  fat,  and  whether  or  not  the  fat 
is  in  excess  in  any  given  stool  preparation  can  be  told  only  by  a 
certain  amount  of  experience  with  the  method.  If  a  baby  is 
doing  well  in  every  way,  it  is  not  necessary  to  change  the  food 
if  there  is  a  sUght  excess  of  fat  in  the  stool. 


CONSTIPATION  73 

This  method,  used  in  this  way,  gives  the  total  fat  in  the  stool 
and  does  not  differentiate  between  neutral  fat,  fatty  acids,  and 
soaps.  What  one  wants  to  know  in  most  stools  is  the  total  fat 
content,  so  I  will  not  go  into  the  technic  for  the  differentiation 
of  soap,  etc. 

The  test  for  starch  is  simpler : 

Add  a  drop  or  two  of  official  tincture  of  iodin  diluted  1  :  15 
with  95  percent  alcohol  to  a  small  portion  of  the  stool,  and  ex- 
amine under  the  microscope.  Starch-granules  stain  dark  blue. 
It  is  abnormal  for  there  to  be  any  but  the  very  smallest  amount 
of  starch  in  a  stool. 

CONSTIPATION 

I  will  finish  the  lecture  by  talking  very  briefly  about  consti- 
pation. Constipation  in  small  babies  and  in  children  during 
the  second  year  is  an  extremely  common  condition  and  one  hard 
to  deal  with.  There  may  be  a  number  of  causes.  The  first  is 
mechanical.  The  large  intestine  is  relatively  a  good  deal  longer 
in  a  child  than  in  an  adult.  The  sigmoid  flexure  is  longer  and 
the  mesentery  is  longer.  There  are  thus  a  good  many  chances 
for  kinks  in  the  intestine,  which  may  partially  obstruct  the 
passage  of  stools.  It  is  well  to  bear  in  mind  that  this  is  cer- 
tainly sometimes  the  cause  in  some  of  the  severe  cases. 

There  are  a  great  many  other  causes,  too,  but  we  need  not  go 
through  all,  and  will  take  up  only  the  two  most  important. 
The  first  is  atony  of  the  abdominal  muscles  and  intestine;  the 
second  is  the  character  of  the  food. 

In  a  great  many  babies  constipation  may  be  caused  by  the 
flaccid  condition  of  the  intestines  and  abdominal  muscles. 
The  child  has  not  enough  strength  in  its  abdominal  muscles  to 
strain  down  and  force  out  the  feces.  The  abdomen  is  verj'- 
flabby.  Of  course,  the  treatment  of  such  a  case  as  this  is  to 
increase  the  general  strength  and  well-being  of  the  child,  if 
possible.  Nux  vomica  is  usually  a  good  drug  to  use.  In  an 
older  child  exercise  of  the  abdominal  muscles  is  valuable.  Of 
course,  if  there  is  anemia  or  any  diseased  condition,  iron  is 
indicated  for  the  anemia  and  suitable  drugs  for  the  other  con- 
ditions. 

Constipation  may  be  caused  by  either  too  little  or  too  much 


74  INFANT  FEEDING    (BOSTON  METHODS) 

fat  in  the  food.  If  the  food  is  very  low  in  fat,  there  is  hkely  to 
be  so  much  of  the  food  absorbed  that  not  enough  is  left  in  the 
intestine  to  cause  a  good  movement  of  the  bowels.  If  there  is 
too  much  fat  in  the  food,  constipation  may  sometimes  be  caused 
by  the  formation  of  hard,  dry  *'soap  stools." 

These  are  the  most  usual  causes  of  constipation. 

If  a  baby  who  is  supposed  to  be  constipated  has  a  stool  the 
moment  his  anus  is  irritated  with  a  suppository  or  a  piece  of 
oiled  paper,  he  has  not  constipation  at  all,  but  does  not  defecate 
simply  because  he  is  lazy  and  does  not  care  particularly  whether 
he  empties  his  bowels  or  not.  All  that  is  needed  in  such  a  case 
as  this  is  training. 

What  is  to  be  done  for  a  case  of  constipation?  First,  let  me 
say  that  in  a  good  many  cases,  no  matter  what  is  done,  the 
results  are  poor. 

Diet. — The  diet  is  of  great  importance.  If  the  child  is  fed  on 
cereal  waters,  oatmeal  is  the  best  one  to  use,  as  it  is  somewhat 
irritating  to  the  intestine  and  will  help  to  cause  peristalsis.  If 
the  child  is  not  getting  enough  fat,  give  more;  if  it  is  getting  too 
much,  cut  it  down.  Properly  prepared  green  vegetables  are  of 
value,  chopped-up  spinach,  celery,  or  carrots  being  very  good. 
Orange-juice  or  prune-juice  or  finely  scraped  apple  will  some- 
times help. 

The  malt-sugar  preparations,  such  as  maltine  malt  soup,  are 
often  of  great  value,  as  maltose  is  very  laxative,  and  sometimes 
obstinate  constipation  in  a  small  baby  can  be  corrected  by  sub- 
stituting malt  for  milk-sugar  without  any  other  measures. 
Dextri-maltose,  however,  is  constipating,  owing  to  its  high  con- 
tent of  dextrins. 

Drugs. — In  the  atonic  cases  tincture  of  nux  vomica  is  some- 
times of  great  value,  and  may  do  more  good  than  either  diet  or 
cathartics. 

Iron  is  indicated  if  the  child  is  anemic.  "  Eisenzucker " 
(saccharated  oxid  of  iron)  is  the  best  preparation  to  use,  as  some 
of  the  other  iron  preparations  have  a  tendency  to  cause  consti- 
pation. 

Laxatives. — Use  laxatives  as  little  as  possible  in  the  treatment 
of  constipation;  they  may  relieve  the  condition  for  a  while, 
but  do  not  get  at  the  cause  of  it. 


CONSTIPATION  75 

Such  cathartics  as  castor  oil  and  calomel  should  not  be  used; 
they  are  too  irritating  for  continued  use. 

The  best  laxative  for  small  babies  is  milk  of  magnesia,  and  for 
older  babies  and  children,  phenolphthalein,  in  doses  of  from  1  to 
3  grains. 

Agar-agar,  which  is  a  preparation  of  finely  ground  seaweed, 
may  be  of  value.  It  is  given  in  doses  of  a  teaspoonful  two  or 
three  times  a  day,  mixed  up  with  the  child's  cereal  or  potato. 
Of  course,  it  cannot  be  used  for  babies  who  take  only  milk.  It 
is  not  absorbed,  but  increases  the  bulk  of  the  stool  by  swelling, 
which  tends  to  cause  a  good  movement. 

The  various  mineral  oils  which  are  on  the  market  are  also  of  a 
certain  amount  of  value. 

Suppositories  are  bad  for  continued  use  as  they  establish  a 
bad  habit  for  the  baby  and  make  it  think  that  it  cannot  have  a 
movement  of  its  bowels  unless  previously  stimulated  with  a 
suppository.  If  enemas  have  to  be  used,  plain  soap  and  water 
ones  are  the  best. 

Constipation  is  a  very  fussy  condition  to  treat,  and  requires  a 
good  deal  of  care.  I  have  merely  attempted  to  give  a  very  brief 
summary  of  some  of  its  most  important  aspects. 


LECTURE  V 
DIARRHEAS  OF  INFANCY 

1.  Nervous. 

2.  Mechanical. 

3.  Fermentative. 

(a)  Carbohydrate  form. 
(6)  Protein  form. 

4.  Infectious: 

/  N    [Dysentery. 

^  ^   \  Streptococcus. 

(&)  Gas  bacillus. 
I  am  going  to  talk  today  about  the  diarrheas  of  infancy. 
There  is  a  great  deal  of  difference  of  opinion  among  various 
pediatric  teachers  and  schools  about  the  etiology  and  treatment 
of  these  diarrheas,  so  I  have  no  right  to  speak  dogmatically  in 
discussing  such  a  question,  but  am  going  to  do  so  for  the  sake  of 
clearness. 

What  is  diarrhea?  What  causes  diarrhea  of  any  sort? 
Diarrhea  is  caused  by  increased  intestinal  peristalsis.  That  is 
at  the  bottom  of  every  diarrhea,  whether  it  be  of  a  baby  or  of  an 
adult.  Increased  peristalsis  may  be  brought  about  by  a  num- 
ber of  causes,  as  follows: 

1.  Reflex  nervous  influences. 

2.  Irritation  of  the  intestine  mechanically  by  seeds,  skins  of 
fruit,  improperly  chewed  food,  etc. 

3.  Irritation  of  the  intestine  by  injurious  chemical  products 
of  food  decomposition. 

4.  Bacterial  infection  of  the  intestinal  mucous  membrane. 
What  sorts  of  diarrhea  are  seen  in  infancy?     Of  course,  all 

diarrheas  are  not  the  same,  and  it  is  not  enough  to  say,  in  the 

case  of  any  baby  who  has  diarrhea,  that  it  has  "ileocolitis"  or 

"summer  complaint."     It  is  necessary  to  diagnose  the  diarrhea 

more  accurately  and  determine  what  type  of  diarrhea  it  is,  and 

76 


DIARRHEAS   OF   INFANCY  77 

to  what  it  is  due  before  it  can  be  intelligently  treated,  for 
different  sorts  of  diarrhea  require  different  treatment. 

NERVOUS  DIARRHEA 

First  of  all,  there  is  a  nervous  diarrhea.  Such  a  diarrhea  as 
this  may  be  caused  by  infection  or  disturbance  of  one  sort  or 
another  outside  of  the  digestive  tract,  reflexly  causing  increased 
intestinal  peristalsis,  and  thus  a  diarrhea.  There  is  no  question 
of  any  bacterial  infection  of  the  intestine  in  such  a  diarrhea  as 
this.  This  type  of  diarrhea  may  be  seen  with  otitis  media,  or 
with  any  acute  infection  which  disturbs  the  equiUbrium  of  the 
child.  Again,  nervous  diarrhea  may  be  caused  by  heat,  by 
prostration,  by  teething,  or  by  undue  excitement.  Nervous 
diarrhea  is  usually  controlled  by  reducing  the  food.  It  is  often 
best,  in  very  hot  weather,  to  weaken  the  food,  and  also  during 
severe  teething,  or  in  acute  infections,  such  as  pneumonia, 
measles,  etc. 

MECHANICAL  DIARRHEA 

Mechanical  diarrhea  is  caused  by  irritation  of  the  intestine  by 
such  things  as  seeds,  skins  of  fruit,  and  various  sorts  of  indiges- 
tible material.  The  child's  intestine  is  much  more  susceptible  to 
irritation  of  this  sort  than  is  that  of  the  adult,  and  this  is  why  it 
is  wrong  to  feed  raw  fruit  or  coarse  green  vegetables  to  small 
children.  There  is  nothing  particularly  to  be  said  about  this 
type  of  diarrhea.  The  stools  always  contain  portions  of  un- 
digested material,  so  the  cause  of  the  diarrhea  is  readily  ascer- 
tained. A  diarrhea  of  this  type  is  likely  to  be  accompanied  by 
more  gastric  disturbance  than  are  most  of  the  other  diarrheas  of 
infancy  and  childhood.  The  treatment  is  thoroughly  to  empty 
the  intestines  with  calomel  or  castor  oil,  to  withhold  food  for 
twenty-four  hours,  and  then  to  start  in  with  a  weak,  easily 
digested  food,  keeping  the  child  on  a  rather  scanty  diet  for  a  few 
days,  after  which  the  regular  diet  may  be  resmned. 

FERMENTATIVE  DIARRHEA 

Fermentative  diarrhea,  the  third  type,  is  an  extremely  com- 
mon condition.  In  Boston  we  see  more  cases  of  this  type  than 
of  any  other.     Probably  many  of  your  cases,  too,  are  of  the  fer- 


78  INFANT  FEEDING    (BOSTON  METHODS) 

mentative  type.  This  is  a  diarrhea  caused  by  the  abnormal 
decomposition  of  food  material  in  the  intestine,  giving  rise  to 
products  which  irritate  the  intestinal  mucous  membrane  and 
cause  diarrhea.  The  mucous  membrane  is  not  attacked  by  bac- 
teria in  this  condition.  It  is  simply  the  food  in  the  intestine 
that  is  attacked  and  decomposed,  and  the  resulting  products 
irritate  the  intestine  and  stimulate  it  to  increased  peristalsis. 
Diarrhea  of  this  type  may  be  of  two  sorts — the  carbohydrate 
form,  in  which  the  carbohydrates  in  the  intestine  are  the  sub- 
stances that  are  being  decomposed,  with  the  formation  of  acid 
end-products;  and  the  protein  form,  in  which  the  protein  sub- 
stances are  being  decomposed,  with  alkahne  end-products. 

By  all  odds  the  most  common  type  is  the  carbohydrate  form, 
and  this  is  the  usual  "summer  diarrhea"  that  is  seen  in  infants. 
It  occurs  especially  in  the  summer,  and  is  rarely  seen  in  the  cool 
months.  The  etiology  may  be  due  to  many  factors  and  con- 
ditions. It  is  unquestionably  due  partly  to  heat;  but  the  exact 
way  in  which  heat  influences  the  baby  is  not  well  understood. 
It  may  be  caused  by  feeding  too  much  sugar  to  the  baby,  either 
as  too  high  a  sugar  f)ercentage,  or  as  too  much  food  at  a  feeding. 
The  sugar  is  not  absorbed,  and  what  is  left  behind  ferments. 
It  may  be  caused  by  dirty  milk,  which  carries  into  the  intestine 
all  sorts  of  harmful  organisms:  the  Bacillus  proteus,  the  gas 
bacillus,  the  colon  bacillus,  etc.  There  has  been  much  dis- 
cussion about  the  exact  organism  which  causes  fermentative 
diarrhea,  but  the  question  of  the  bacteriology  of  the  intestine  is 
so  compUcated  that  it  is  impossible  to  lay  the  blame  at  the  door 
of  any  one  organism.  We  know  that  usually  it  is  caused  by 
organisms  of  a  number  of  different  sorts  which  enter  the  body  in 
contaminated  milk,  but  we  also  know  that  it  may  be  caused  by 
the  normal  flora  of  the  intestine,  under  certain  conditions. 
Sunmier  is,  of  course,  the  most  favorable  time  for  milk  to  be- 
come infected.  If  the  milk  is  pasteurized  or  sterilized,  or  if  it  is 
certified  milk,  it  is  very  unlikely  to  produce  fermentative  diar- 
rhea, and  the  condition  is  not  nearly  so  common  among  the 
better  classes,  who  take  good  care  of  their  milk,  as  it  is  among 
the  poorer  classes,  who  do  not. 

The  prominent  symptom  of  fermentative  diarrhea  due  to 
carbohydrate  decomposition  is  the  passage  of  loose,  green,  acid 


DIARRHEAS   OF   INFANCY  79 

stools  containing  mucus.  The  stools  are  always  strongly  acid  and 
smell  acid.  They  are  usually  green.  The  number  may  vary  a 
good  deal — there  may  be  three  or  four  or  five  in  a  day,  or 
twenty  or  twenty-five.  The  severity  of  the  attack  may  vary 
a  great  deal.  The  child  may  appear  not  to  be  sick  at  all,  but 
may  have  these  stools;  or  there  may  be  a  great  deal  of  toxemia, 
with  high  temperature,  and  the  child  may  die.  The  tempera- 
ture may  be  normal  or  may  be  very  high.  There  is  not  a  great 
deal  of  vomiting,  because  the  condition  is  primarily  an  intes- 
tinal one,  and  the  stomach  has  very  little  to  do  with  it.  The 
buttocks  are  likely  to  be  red  and  irritated  from  the  strongly 
acid  stools.  The  abdomen  in  the  severe  cases  may  be  sunken, 
also  the  eyes  and  the  fontanel.  Nervous  symptoms  are  not  so 
common  as  in  true  "infectious  diarrhea."  You  have  all  seen 
so  many  of  these  cases  that  it  is  not  necessary  to  discuss  the 
symptoms  further. 

The  sugar  in  the  intestine  is  attacked  by  bacteria  and  broken 
down.  Formic,  acetic,  and  butyric,  as  well  as  many  other 
acids  are  formed  from  the  breaking  down  of  the  sugar.  A 
certain  amount  of  formaldehyd  is  also  likely  to  be  produced. 
It  is  surprising  to  see  how  much  strong  acetic  and  butyric  acid 
may  be  recovered  from  the  stools  of  babies  with  this  condition, 
and  when  one  realizes  how  much  concentrated  acid  is  present, 
it  is  easy  to  understand  how  tremendously  the  intestine  is  irri- 
tated by  it. 

Of  course,  in  this  condition  the  absorption  of  all  the  food 
elements  is  lessened,  partly  on  account  of  the  increased  peris- 
talsis and  partly  on  account  of  the  abnormal  acidity  of  the 
intestine. 

There  is  likely  to  be  an  acidosis  present  in  a  good  many  of  the 
cases,  partly  duo  to  the  greatly  increased  loss  of  alkah  in  the 
diarrheal  stools  and  partly  due  to  the  usually  diminished  ex- 
cretion of  the  kidneys  and  the  abnormal  breaking  down  of  body 
fat  if  the  baby  is  not  taking  much  milk. 

The  prognosis  varies  a  great  deal.  It  is  usually  very  good  in 
the  mild  cases  in  large,  strong  babies.  It  is  doubtful  or  bad  in 
the  more  severe  cases  in  small,  poorly  nourished  babies.  Often 
a  small  baby  will  die  in  twenty-four  hours  from  fermentative 
diarrhea. 


80  INFANT   FEEDING    (BOSTON  METHODS) 

Treatment. — You  may  be  sure  in  any  diarrhea  that  if  the 
stools  are  green,  acid  smelling,  and  strongly  acid  in  reaction  the 
condition  is  due  to  sugar  fermentation.  What  are  the  indica- 
tions for  treatment?  As  the  condition  is  due  to  a  sugar  fer- 
mentation, it  is  reasonable  to  give  a  milk  as  low  in  its  sugar  con- 
tent as  possible,  to  arrest  this  fermentation.  If,  in  the  food,  a  high 
protein  content  can  be  combined  with  this  low  sugar  content,  a  good 
deal  will  have  been  gained,  for  the  disintegration  products  of  protein 
are  alkaline  in  reaction  and  will  help  to  neutralize  the  acid  condi- 
tion in  the  intestine,  restoring  it  to  its  normal  balance.  The  with- 
drawal of  sugar  and  the  substitution  of  protein  will  also  tend  to 
inhibit  the  growth  of  the  bacteria  which  have  been  causing  the 
condition. 

These  are  the  principles  of  treatment. 

Details  of  Treatment. — In  severe  acute  cases  it  is  usually 
better  to  starve  the  child  for  twenty-four  hours,  giving  it  merely 
water.  In  the  milder  cases  starvation  is  not  at  all  necessary. 
As  to  purgatives,  personally  I  do  not  at  all  believe  in  giving 
them  to  cases  of  fermentative  diarrhea  due  to  carbohydrate, 
when  the  child  is  having  10  to  15  or  20  stools  a  day;  as  it  is 
cleaning  itself  out,  and  it  is  not  necessary  to  have  any  further 
cleaning.  The  intestine  is  already  very  much  irritated,  and  it 
is  poor  therapeutics  to  irritate  it  any  more.  But  if  the  baby  is 
having  only  three  or  four  bad-looking  stools,  by  all  means  give 
a  purge  of  castor  oil  or  calomel  to  clean  out  the  intestine.  After 
the  starvation  period  of  twenty-four  hours,  feeding  can  be 
started.  There  are  two  or  three  different  methods  which  can  be 
used,  but  the  principle  is  the  same  in  all. 

1.  Start  on  skimmed  milk  and  water  dilutions,  giving  the 
baby  such  a  formula  as  this:  Skimmed  milk,  one-half;  water, 
one-half.  The  percentage  is  this :  Fat,  0;  sugar,  2.25;  protein, 
1.6.  Of  course,  no  definite  rules  can  be  laid  down  for  increasing 
the  strength  of  the  milk,  as  this  will  depend  upon  the  clinical 
condition.  Keep  the  fat  low  for  a  considerable  length  of  time, 
also  the  sugar,  and  go  up  on  the  protein.  When  sugar  is  added, 
use  a  malt-sugar  preparation  instead  of  milk-sugar.  Keep  the 
sugar  very  low  until  the  stools  have  become  solid. 

2.  Another  way  of  feeding  these  cases  is  by  the  use  of  "Ei- 
weiss"  milk,  of  which  I  have  already  spoken  in  the  last  lecture. 


DIARRHEAS   OF   INFANCY  81 

This  is  extremely  satisfactory  in  such  cases  and  they  will  get 
well  much  more  quickly  than  with  simply  skimmed  milk  and 
water.  The  disadvantage  is  that  Eiweiss  milk  is  hard  to  make, 
but  if  one  is  dealing  with  an  intelligent  family,  they  can  make 
this  milk,  and  it  is  by  all  odds  the  best  thing  to  feed  these  cases 
on,  because  one  can  get  in  it  a  much  higher  protein  percentage 
and  a  lower  sugar  percentage  than  by  any  other  means.  Ei- 
weiss milk  has  this  composition,  you  remember:  Fat,  2.5; 
sugar,  1.5;  protein,  3.5;  or  if  skimmed  milk  is.  used  instead  of 
whole  milk,  the  fat  is  reduced  nearly  to  zero. 

3.  There  is  another  method:  the  use  of  skimmed  milk  and 
water  mixtures  to  which  powdered  casein  has  been  added.  The 
great  trouble  about  this  is  that  it  is  hard  to  get  powdered  casein. 
There  was  a  good  product  on  the  market  some  time  ago  called 
"Larosan,"  but  I  am  not  sure  whether  this  can  be  obtained  now. 
Buttermilk  is  also  sometimes  of  value  in  feeding  these  cases,  as 
it  combines  a  high  protein  with  a  fairly  low  sugar  content.  So 
much  for  the  feeding. 

Drugs. — I  do  not  wish  to  give  the  impression  that  drugs  are 
of  no  value  in  treating  this  condition,  but  I  distinctly  do  wish  to 
give  the  impression  that  the  regulation  of  the  diet  is  by  far  the 
most  important  part  of  the  treatment.  It  is  very  rarely  neces- 
sary to  give  a  drug  of  any  sort  to  a  baby  with  fermentative 
diarrhea. 

Purgatives. — As  I  said  before,  purge  the  baby  with  castor  oil 
or  calomel  if  it  has  not  already  cleaned  itself  out  well;  if  it  is 
having  numerous  stools  already,  give  no  purgative.  It  is  a 
great  mistake  to  give  repeated  daily  doses  of  calomel  or  castor  oil 
to  a  baby  who  is  already  exhausted  by  diarrhea. 

Bismuth. — Bismuth  does  very  little  good  in  fermentative 
diarrhea,  and  it  obscures  the  stool  picture,  so  one  cannot  tell 
the  nature  of  the  stool,  and  thus  cannot  regulate  the  diet  in- 
telligently. Proper  food  regulation  will  usually  stop  the  diar- 
rhea without  using  bismuth. 

Opium. — Theoretically,  opium  is  contraindicated  because  it 
is  unwise  to  tie  up  the  intestine  and  thus  favor  absorption  of 
toxic  material.  Practically,  when  a  baby  is  having  many 
watery  stools  a  day,  with  a  good  deal  of  straining  and  tenesmus, 

6 


82  INFANT  FEEDING    (BOSTON  METHODS) 

with  perhaps  a  prolapsed  rectum,  it  is  wise  to  give  opium  in 
some  form,  usually  paregoric,  to  relieve  it. 

Intestinal  Antiseptics. — The  intestinal  antiseptics  are  of  very 
little  value  in  treating  fermentative  diarrhea :  if  you  give  enough 
to  sterilize  the  intestine,  you  give  enough  to  kill  the  baby. 
Bulgar  tablets,  which  are  so  commonly  used,  are  very  likely  to 
be  inactive,  and  I  am  very  skeptical  about  their  value,  even  if 
they  are  active. 

Colonic  Irrigations. — The  trouble  in  fermentative  diarrhea  is 
usually  so  high  up  in  the  intestine  that  Uttle  benefit  is  to  be 
obtained  from  colonic  irrigation. 

Fluid. — It  is  extremely  important  to  give  the  baby  plenty  of 
fluid,  either  by  mouth,  rectum,  or  by  subcutaneous  injection, 
if  necessary.  Next  to  the  feeding,  this  is  the  most  important 
part  of  the  treatment. 

Alkalis. — Theoretically,  it  would  seem  that  as  the  trouble  in 
fermentative  diarrhea  due  to  carbohydrate  fermentation  is 
caused  by  the  excessive  production  of  acid  in  the  intestine,  al- 
kalis would  be  indicated.  Practically,  it  is  much  easier  to 
change  the  reaction  of  the  intestine  by  the  use  of  suitable  food 
than  by  alkahs.  In  certain  cases  of  fermentative  diarrhea 
there  may  be  a  good  deal  of  acidosis,  however,  which  may  be 
manifested  by  rapid  and  labored  breathing,  by  stupor,  or  by 
extreme  restlessness.  If  acidosis  is  suspected,  an  alkali  is  in- 
dicated. Sodium  bicarbonate  may  be  used,  either  by  mouth  or 
by  rectum,  usually  best  by  rectum,  as  it  has  a  good  deal  of 
tendency  to  upset  the  stomachs  of  small  babies. 

You  will  see  that  I  am  somewhat  of  a  drug  nihilist  as  regards 
this  condition;  to  my  own  cases  I  rarely  give  a  drug,  with  the 
exception  of  an  occasional  dose  of  opium  or  castor  oil.  I 
understand  perfectly  that  a  doctor  has  to  give  drugs  to  many 
■  people  if  he  wants  to  keep  them  as  patients,  and  do  not  believe 
that  such  drugs  as  bismuth,  salol,  etc.,  do  any  harm. 

In  fermentative  diarrhea  due  to  protein  the  general  symptoms 
are  very  much  the  same  as  in  the  carbohydrate  form,  which  we 
have  been  discussing,  except  for  the  stools.  The  stools  in  pro- 
tein fermentative  diarrhea  are  loose,  watery,  brown,  and  rather 
musty  or  foul  smelUng,  and  they  are  alkaline  in  reaction.  The 
condition  is  due  to  decomposition  of  protein  in  the  intestine; 


DIARRHEAS   OF   INFANCY  83 

therefore  it  is  treated  by  giving  a  milk  low  in  protein  and  high 
in  carbohydrate.  The  first  food  which  it  is  usually  best  to 
give  is  a  5  to  7  percent  solution  of  milk-sugar,  to  which  barley 
water  may  or  may  not  be  added,  keeping  the  protein  low  for  a 
while,  and  gradually  increasing  the  strength  of  the  food  by  add- 
ing skimmed  milk  or  whole  milk,  and  more  sugar.  These  cases 
will  usually  do  well  with  proper  treatment,  but  some  of  them 
may  be  troublesome.  The  general  treatment  is  the  same  as 
for  the  carbohydrate  form.  A  hundred  carbohydrate  cases 
are  seen  to  one  of  the  protein  type. 

INFECTIOUS  DIARRHEA 

Infectious  diarrhea  is  the  type  of  diarrhea  that  most  of  you 
see  down  here.  It  is  called  by  different  names:  ileocoUtis, 
dysentery,  etc.  This  condition  may  be  due  to  a  number  of 
organisms,  which  may  be  divided  into  two  groups, — the  dysen- 
tery bacillus  and  the  streptococcus, — which  I  put  together  be- 
cause the  treatment  for  them  both  is  the  same;  and  the  gas 
bacillus  group,  for  which  the  treatment  is  different.  As  you 
will  note,  this  classification  is  based  on  the  treatment.  The 
etiology  is  infected  milk  in  nearly  all  cases,  and  if  the  disease  is 
seen  in  breast-fed  babies,  it  means  they  have  been  having  some 
food  in  addition  to  the  breast  milk,  or  may  possibly  have  re- 
ceived the  infection  through  water. 

In  infectious  diarrhea  there  is  an  actual  invasion  of  the  intes- 
tinal mucous  membrane  by  bacteria;  thus  it  is  a  different  thing 
entirely  from  fermentative  diarrhea. 

First  of  all  I  want  to  speak  of  the  gas  oacillus  type.  There 
has  been  a  great  deal  of  discussion,  especially  in  Boston,  as  to 
just  what  role  the  gas  bacillus  plays  in  infectious  diarrhea. 
We  find  it  in  a  certain  number  of  cases,  and  we  know  that  when 
we  get  rid  of  it  the  cases  improve  a  great  deal.  From  that  line 
of  reasoning  we  consider  that  in  these  cases  the  gas  bacillus  is 
the  cause  of  the  disease.  Some  men  say  that  it  has  nothing  at 
all  to  do  with  it,  and  that  it  is  simply  present  in  the  intestine, 
doing  httle  harm,  and  that  the  infection  is  due  to  the  dysentery 
bacillus,  and  that  if  a  man  will  look  for  that  carefully  enough 
he  will  always  find  it.     Personally,  I  think  most  cases  are 


84  INFANT  FEEDING    (BOSTON  METHODS) 

caused  by  the  dysentery  bacillus,  but  I  do  believe  that  a 
certain  number  of  cases  are  caused  by  the  gas  bacillus.  It 
is  important  to  differentiate  them  because  the  treatment  is 
different  for  each  type.  This  must  be  done  by  stool  cul- 
tures. CUnically,  the  two  cannot  be  told  apart  except  that 
the  dysentery  type  is  hkely  to  be  a  little  more  severe.  We 
will  speak  of  the  differentiation  of  the  two  types  a  little 
later. 

Let  us  take  up  the  dysentery  type,  which  is  the  one  usually 
seen.  The  trouble  is  in  the  large  intestine  and  in  the  lower 
part  of  the  small  intestine.  There  may  be  only  a  catarrhal  in- 
flammation present,  or  there  may  be  small  superficial  ulcers  or 
deep  ulcers.  The  symptoms  may  vary  considerably  according 
to  the  severity  of  the  infection.  The  onset  is  likely  to  be  sud- 
den. The  stools  may  vary  a  good  deal  in  number,  as  many  as 
20  or  30  being  passed  each  day.  They  may  be  very  small, 
usually  only  small  amounts  of  blood  and  mucus,  pus,  and  slime 
being  passed  after  the  first  day  or  two.  Some  cases  may  show 
extreme  nervous  systems,  much  resembling  meningitis  at  the 
onset.  The  only  way  to  rule  out  meningitis  is  to  do  a  lumbar 
puncture  and  examine  the  spinal  fluid.  The  temperature  may 
vary  a  good  deal,  in  some  cases  being  very  slight,  in  others  very- 
high;  in  most  cases  it  is  moderate,  but  continuous.  The  evi- 
dences of  toxemia  are  usually  severe,  and  these  babies  certainly 
are  very  sick  in  the  great  majority  of  cases.  You  have  all  seen 
so  much  infectious  diarrhea  that  it  would  be  a  waste  of  your 
time  to  go  further  into  the  symptoms. 

Treatment.— A  good  many  different  methods  of  treatment 
have  been  used  for  the  condition.  The  principle  to  remember 
is  this :  The  dysentery  bacillus  lives  upon  protein  food  much  more 
readily  than  it  does  upon  carbohydrate,  and  the  products  which  it 
forms  from  protein  are  much  more  toxic  than  the  products  from 
carbohydrate,  so  feed  these  cases  on  a  low  protein  diet  and  a  fairly 
high  carbohydrate,  giving  the  baby  as  much  food  as  it  can  reason- 
ably take  without  being  upset.  Carbohydrate  food  tends  to  dis- 
courage the  growth  of  the  dysentery  bacillus — protein  food  en- 
courages it.  That  is  the  principle  of  the  treatment  of  cases  of 
diarrhea  due  to  the  dysentery  bacillus  or  to  the  streptococcus. 
It  is  usually  best  to  give  these  cases  an  initial  purge  of  calomel  or 


DIARRHEAS   OF  INFANCY  85 

castor  oil,  then  starve  them  for  twenty-four  hours,  giving  nothing 
but  a  5  or  6  percent  sugar  solution.  We  used  to  starve  them  for 
as  long  as  ten  days  at  a  time,  but  have  stopped  that,  because  we 
found  out  that  they  do  a  great  deal  better  if  they  are  not  starved 
so  long.  We  start  the  feeding  by  adding  barley  water  to  the 
sugar  solution,  and  later  add  skimmed  milk  to  this.  Some  of 
these  children  do  not  like  to  eat,  but  they  have  to  have  fluid 
and  they  have  to  have  food,  so  feed  them  with  a  stomach-tube 
if  they  will  not  take  the  milk. 

The  gastric  symptoms  are  usually  not  severe,  so  there  will, 
in  most  cases,  not  be  much  vomiting.  If  there  is  vomiting,  the 
thing  to  do  is  to  wash  out  the  stomach  and  stop  the  food  for  a 
few  feedings. 

There  are  no  definite  rules  that  can  be  laid  down  for  the  feed- 
ing of  these  cases.  Size  up  each  case  and  remember  the  prin- 
ciple of  fitting  the  food  to  what  the  individual  baby  can  take, 
keeping  it  rather  low  in  protein  and  high  in  carbohydrate,  and, 
especially  during  convalescence,  low  in  fat,  because  the  diges- 
tion of  fat  is  very  poor  during  the  whole  course  of  the  disease 
and  convalescence.  A  prominent  pediatrician  said  last  year 
that  he  had  come  to  the  conclusion  that  the  best  way  to  treat 
infectious  diarrhea  was  to  consider  a  case  very  much  as  a  case 
of  typhoid  fever.  This  is  sensible,  for  the  dysentery  bacillus  is 
closely  allied  to  the  typhoid  bacillus,  and  the  pathology  of  the 
two  conditions  is  somewhat  the  same. 

To  clinch  the  question  of  feeding  these  cases,  let  us  take  a 
supposititious  case  and  feed  it;  but  remember  that  this  par- 
ticular feeding  might  apply  to  one  baby,  and  not  to  another. 

Let  us  say  that  our  patient  is  sixteen  months  old,  and  is  seen 
the  first  day  he  is  taken  sick,  and  has  had  four  stools  with  blood 
and  mucus. 

1.  A  purge — castor  oil  or  calomel. 

2.  Withdraw  food  for  twenty-four  hours,  giving  plenty  of 
water — 8  ounces  every  three  hours,  sweetened  with  saccharin, 
if  necessary. 

3.  Start  feeding  with  a  solution  of  8  percent  lactose,  giving 
water  between  each  feeding. 

Lactose  solution,  8  ounces  every  three  hours.  Water,  4  ounces 
between  each  lactose  feeding. 


86  INFANT  FEEDING    (BOSTON  METHODS) 

4.  After  a  day  of  the  lactose  feeding  add  1  percent  barley 
starch  to  the  sugar  solution.     Feed  this  for  twenty-four  hours. 

5.  Feed  lactose  and  starch  solution,  7  ounces,  skimmed  milk 
1  ounce. 

Gradually  increase  the  skimmed  milk  in  this  feeding  until, 
when  the  baby  is  nearly  well,  he  will  be  taking  possibly  this: 

Skimmed  milk 6  ounces 

Barley-water 2  ounces 

Dextri-maltose 1  dram 

Soon  to  this  can  be  added  barley  jelly,  three  tablespoonfuls  a 
day,  and  if  he  takes  this  well,  powdered  zwieback  can  be  given. 
The  last  thing  to  do  is  to  increase  the  fat  in  the  food,  and  this  is 
done  by  substituting  an  ounce  of  whole  milk  for  an  ounce  of 
sldmmed  milk  until  the  baby  is  taking  entire  whole  milk. 

Of  course,  this  feeding  would  have  to  be  modified  for  a  younger 
baby,  and  a  weaker  milk  would  be  given,  but  the  principle  is  the 
same. 

As  to  the  rest  of  the  treatment,  the  most  important  single  thing 
in  the  whole  treatment  is  to  keep  the  baby  filled  up  with  fluid.  If 
't  cannot  be  given  by  mouth. or  by  rectum,  it  will  have  to  be 
given  subcutaneously.  This  is  not  hard  to  do.  Do  not  let  these 
babies  get  dried  out.  Give  them  salt  solution  under  the  skin 
right  away:  a  teaspoonful  of  salt  to  a  pint  of  water.  More 
babies  die  from  getting  dried  out  in  this  disease  than  from  any 
other  one  thing. 

For  excessive  fever,  the  best  treatment  is  baths — a  sponge- 
bath  of  one-half  alcohol  and  one-half  water,  at  80°  F.,  or  a  fan 
bath,  wrapping  the  baby  in  cheese-cloth,  sprinkling  it  with  water, 
and  fanning  him,  or  a  cold  bath  at  70°  F.  Do  not  give  anti- 
pyretic drugs — they  are  all  depressants.  Some  babies  have  a 
subnormal  temperature  and  have  to  be  stimulate'd  by  hot-water 
bags  or  hot  salt  solution  by  rectum.  Colonic  irrigation  may  be 
of  some  value  in  treating  the  disease,  and  will  do  no  harm. 
If  it  does  not  disturb  the  baby,  it  is  a  good  idea  to  give  one  once 
a  day,  of  normal  salt  solution  or  4  percent  sodium  bicarbonate 
solution.  In  cases  that  do  not  clear  up  well  and  continue  to 
have  pus  in  the  stools  too  long  it  is  sometimes  well  to  use  a  2 
percent  solution  of  silver  nitrate  for  the  irrigation. 


DIARRHEAS   OF   INFANCY  87 

Drug  Treatment.— About  the  same  may  be  said  of  the  drug 
treatment  of  infectious  diarrhea  as  was  said  for  fermentative 
diarrhea. 

Purgatives.— Fmgatives  are  indicated  in  the  beginning  of  the 
disease,  or  during  its  course  if  the  number  of  stools  drops  sud- 
denly and  there  seems  to  be  a  good  deal  of  toxemia.  I  think  it  is 
extremely  bad  practice  to  give  a  purge  every  day  as  a  routine. 

Bismuth. — Bismuth  may  do  some  good  in  coating  over  the 
ulcers  in  the  intestine,  and  by  tending  to  decrease  excessive 
peristalsis.  The  subcarbonate  of  bismuth  is  better  to  use  than 
the  subnitrate,  as  there  is  less  danger  of  poisoning  by  absorption. 

Intestinal  Antiseptics. — These  drugs  do  Kttle  good  in  infectious 
diarrhea,  for  the  organisms  that  cause  it  are  likely  to  be  deep 
down  in  the  ulcers  under  the  mucous  membrane  and  they  can- 
not reach  them.  Also,  large  enough  doses  really  to  be  valuable 
would  probably  kill  the  child. 

Opium. — The  indications  for  opium  in  infectious  diarrhea  are 
the  same  as  for  the  fermentative  type. 

Stimulants. — Stimulants  may  be  needed  if  the  child  is  much 
prostrated.  Strychnin,  camphor,  caffein,  or  alcohol  may  be 
used.  Personally,  I  prefer  caffein  sodium  benzoate  given  sub- 
cutaneously. 

Chloral  and  Sodium  Bromid. — These  drugs  are  indicated  for 
restlessness.  Children  bear  them  well,  and  they  may  be  given 
in  good-sized  doses. 

Now  for  the  gas  bacillus  type  of  diarrhea:  The  treatment  in 
this  condition,  that  is,  the  food  treatment,  is  different  from  the 
treatment  of  the  dysentery  type;  the  rest  of  the  treatment  is 
just  the  same.  The  gas  bacillus  is  an  organism  that  thrives  on 
carbohydrate  food,  so  it  is  absolutely  wrong  to  feed  a  child  with 
a  condition  due  to  the  gas  bacillus  on  carbohydrates.  The  gas 
bacillus  cannot  flourish  if  there  is  a  good  deal  of  lactic  acid  in  the 
intestine,  and  these  cases  will  sometimes  do  remarkably  well  on 
buttermilk  or  on  lactic  acid  milk.  I  do  not  believe  that  the 
bulgar  tablets  are  usually  of  much  value,  because  they  are  so 
hkely  to  be  inactive,  and  buttermilk  or  lactic  acid  milk  made 
with  a  liquid  culture  is  much  better. 

The  rest  of  the  treatment  for  this  type  is  just  the  same  as  for 
the  other  types.     The  feeding  is  the  only  point  that  is  different. 


88  INFANT  FEEDING    (BOSTON  METHODS) 

Get  just  as  much  buttermilk  or  lactic  acid  milk  into  the  child  as 
possible  and  keep  the  carbohydrates  low. 

Most  cases  of  infectious  diarrhea  are  of  the  dysentery  type, 
so  the  treatment  usually  will  be  for  this  type.  The  gas  bacil- 
lus can  be  tested  for  very  easily  by  putting  a  small  portion  of 
the  stool  into  a  test-tube  of  milk,  boiling  it  for  three  minutes, 
then  stopping  it  up  and  incubating  it  for  twenty-four  hours. 
If  the  gas  bacillus  is  present,  the  casein  will  be  coagulated, 
will  be  full  of  holes,  and  will  smell  like  rancid  butter,  due  to  the 
formation  of  butyric  acid  from  the  fat  and  sugar  in  the  milk. 

Usually,  if  a  "gas"  case  is  fed  on  a  high  carbohydrate  food, 
as  would  be  done  for  a  dysentery  case,  the  temperature  will  go 
up,  and  the  baby  will  be  sicker,  so  if  this  happens,  it  is  fair  to 
assume  that  the  other  type  of  treatment,  that  is,  with  butter- 
milk, is  indicated. 

How  is  one  to  tell  infectious  diarrhea  from  the  fermentative 
type?  Ordinarily  in  the  fermentative  form  the  child  is  not  so 
ill.  In  this  type,  too,  there  is  usually  no  blood  in  the  stools,  and 
there  is  never  any  'pus.  In  infectious  diarrhea  there  are  nearly 
always  blood  and  pus  in  the  stools.  Another  thing,  the  tem- 
perature in  fermentative  diarrhea  rarely  continues  elevated  for 
more  than  a  day  or  two.  In  infectious  diarrhea  it  continues 
elevated  for  a  number  of  days. 

Sometimes  when  called  to  a  case  it  is  impossible  to  tell  at  the 
first  visit  which  type  of  diarrhea  it  is.  Under  such  conditions 
it  is  safe  to  clean  the  baby  out  and  starve  it  for  twenty-four 
hours,  and  by  this  time  a  decision  one  way  or  the  other  can 
usually  be  made.  Another  condition  with  which  infectious 
diarrhea  is  sometimes  confused  is  intussusception.  In  this 
condition  the  abdomen  is  likely  to  be  distended:  in  infectious 
diarrhea  it  is  usually  sunken.  A  tumor  may  be  felt  in  intus- 
susception, and  not  in  infectious  diarrhea.  All  the  symptoms 
in  intussusception  are  likely  to  be  more  severe,  and  vomiting 
is  prominent.  The  stools  in  the  two  conditions  may  look  al- 
most exactly  the  same,  but  if  there  is  much  fecal  material  pres- 
ent with  the  blood  and  mucus,  the  case  is  more  Ukely  to  be  one 
of  infectious  diarrhea. 

The  subject  of  these  diarrheas  is  an  extremely  difficult  one  to 
present  in  a  clear  and  clean-cut  manner,  for  the  reason  that  no 


DIARRHEAS   OF   INFANCY  89 

two  people  will  say  the  same  things  about  them,  and  I  know 
perfectly  well  that  there  is  plenty  of  room  for  criticism  and 
difference  of  opinion  about  the  things  I  have  been  telhng  you 
today.  I  have  not  spoken  of  the  old-fashioned  "cholera  in- 
fantum" that  most  of  you  older  men  have  seen,  as  it  is  fortu- 
nately a  very  rare  condition  today,  and  we  practically  never  see 
it  in  Boston. 

There  will  be  no  more  lectures  on  feeding,  and  I  want  to  give 
you  a  very  brief  summary  of  the  central  ideas  of  the  subject — a 
bird's-eye  view  of  the  whole. 

The  subject  of  infant  feeding  is  seemingly  in  chaos — what  is 
believed  in  Boston  is  not  believed  in  Chicago,  what  is  believed 
in  Berlin  is  not  believed  in  New  York,  and  so  on;  what  is  re- 
garded as  gospel  in  one  city  by  one  group  of  pediatricians  may 
be  looked  upon  as  of  very  little  consequence  by  an  equally  cap- 
able group  of  pediatricians  in  another  city.  It  is  obviously  not 
just  or  reasonable  to  suppose  that  intelligent  pediatricians  in 
one  city  do  not  know  how  to  feed  babies  because  they  use 
methods  which  are  different  from  those  used  by  their  confreres 
in  another  city,  and  still  each  group  of  men  firmly  believe  that 
its  own  methods  are  the  correct  ones,  which  is  only  natural.  I 
suppose  that  if  the  end-results  of  the  feeding  work  of  men  of 
equal  experience  in  the  various  cities,  using  different  methods, 
were  to  be  compared,  these  results  would  be  found  to  be  very 
similar;  we  get  at  things  in  different  ways,  hut  get  there. 

I  have  endeavored  to  teach  you  Boston  ideas  of  feeding  en- 
tirely, and  have  paid  no  attention  to  the  ideas  of  men  who  have 
different  methods  than  ours;  not  because  I  beheve  that  they 
are  of  no  value,  but  because  I  believe  our  methods  are  the  most 
reasonable  and  logical,  and  because  it  is  best  to  save  confusion 
by  learning  one  method  instead  of  skimming  over  several. 

Let  us  consider  what  the  basis  of  the  Boston  method  is: 

1.  A  hahy  must  have  a  well-balanced  food. 

2,  He  must  have  enough  of  it  in  fuel  value. 

These  two  propositions  are  self-evident,  and  will  be  admitted 
by  every  one,  no  matter  what  methods  of  feeding  he  uses. 

We  believe,  in  Boston,  that  most  of  the  digestive  troubles  of  babies 
(exclusive,  of  course,  of  such  conditions  as  infectious  diarrhea)  are 
caused  by  an  excess  or  a  deficit  of  one  or  more  of  the  food  elanents  in 


90  INFANT   FEEDING    (BOSTON   METHODS) 

the  milk — fat,  sugar,  protein,  or  salts — or  to  a  faulty  digestion  or 
absorption  of  one  or  more  of  these  elements  when  they  are  perhaps 
in  normal  quxintity  in  the  milk.  Therefore  it  is  reasonable  and 
essential  to  know  approximately  how  mu^h  of  each  of  these  elements 
is  in  the  milk  that  we  feed  to  any  baby.  The  most  convenient  and 
accurate  way  of  expressing  this  quxintity  is  by  percents  of  the  various 
elements.  We  take  into  consideration  the  elementary  composition 
of  the  food,  and  also  the  fuel  value  of  the  food  as  a  whole,  as  ex- 
pressed in  calories,  or  heat  units.  We  determine  what  food  ele- 
ment or  elements  are  causing  the  baby  trouble,  by  a  study  of  his  diet, 
himself,  and  his  stools,  and  regulate  the  subsequent  food  supply  by 
an  increase  or  diminution  of  an  element  or  elements  of  the  food,  or 
of  the  total  quantity  of  food,  according  to  the  indications  thus  de- 
termined. We  lay  especial  stress  on  the  examination  of  the  stools, 
macroscopic  and  microscopic,  and  believe  that  such  examination 
helps  a  great  deal  in  the  proper  regulation  of  the  baby's  diet  by  giving 
u^  a  guide  as  to  what  he  is  or  is  not  digesting. 

This  is  a  brief  exposition  of  the  principles  upon  which  "per- 
centage feeding"  is  based:  there  is  nothing  comphcated  about 
it;  rather  it  tends  to  make  a  difficult  subject  clearer — it  is 
rational,  practical,  and  scientific  at  the  same  time,  and  its 
principles  and  practice  can  be  grasped  by  any  one  who  will  take 
the  trouble  to  give  it  a  little  thought. 


LECTURE  VI 

PYLORIC  STENOSIS— PYLORIC  SPASM— INTUSSUSCEP- 
TION—ACIDOSIS 

In  the  lecture  today  I  am  combining  several  subjects,  which, 
although  unrelated,  will  be  put  together  into  one  lecture,  as 
any  one  of  these  subjects  alone  is  hardly  important  enough  to 
you  to  devote  a  whole  lecture  to  it. 

First,  let  us  consider  pyloric  stenosis  and  pyloric  spasm. 

Pyloric  stenosis,  or  "congenital  hypertrophic  stenosis  of  the 
pylorus,"  as  it  is  sometimes  called,  is  a  congenital  hypertrophy 
of  the  circular  muscle-fibers  of  the  pylorus,  which  causes  a 
stenosis  of  the  orifice. 

Pyloric  spasm  is  a  condition  in  which  there  is  a  nervous  spasm 
of  the  pylorus  which  causes  a  stenosis.  Pyloric  spasm  may 
sometimes  compUcate  a  true  organic  stenosis,  or  it  may  exist 
independently. 

PYLORIC  STENOSIS 

Symptoms.— A  baby,  breast  fed  or  bottle  fed,  will  usually 
start  to  vomit  when  it  is  anywhere  from  a  few  days  to  a  month 
old.  This  vomiting,  in  true  stenosis,  rarely  begins  after  the 
first  month.  The  vomiting  at  first  may  not  be  very  severe,  but 
in  a  few  days  it  becomes  projectile,  and  the  vomitus  may  be 
shot  out  of  the  mouth  to  a  distance  of  two  or  three  feet.  The 
child  will  vomit  whatever  it  eats,  and  the  vomiting  is  uncon- 
trollable by  drugs  of  any  sort,  as  can  be  readily  understood  from 
the  pathology  of  the  condition.  There  is  no  evidence  of  any 
indigestion,  as  shown  by  coHc,  diarrhea,  etc.,  and  the  child  is 
hungry.  The  child  loses  tremendously  in  weight,  due  to  the 
fact  that  it  gets  practically  no  food  into  its  intestine.  The 
stools  are  very  small  in  size  and  constipated,  as  Httle  food 
goes  through  the  pylorus.  These  are  the  important  symptoms 
—the  explosive  vomiting,  the  loss  in  weight,  and  the  small  size 

91 


92  INFANT   FEEDING    (BOSTON  METHODS) 

of  the  stools.  The  condition  occurs  with  equal  frequency  in 
breast-  or  bottle-fed  babies. 

There  is  very  hkely  to  be  a  considerable  dilatation  of  the 
stomach  in  true  pyloric  stenosis;  and  there  may  also  be  visible 
peristalsis  excited  by  stroking  the  skin  over  the  stomach,  the 
peristaltic  waves  running  from  left  to  right  across  the  abdomen. 
They  will  not  be  seen  unless  there  is  something  in  the  stomach. 
There  may  also  be  felt  a  small  tumor — the  enlarged  pylorus. 
This  tumor  is  usually  midway  between  the  tip  of  the  ensiform 
and  the  umbilicus,  about  Yi.  inch  to  the  right  of  the  midline. 
In  some  cases  it  may  not  be  felt  at  all,  but  in  the  majority  it  is 
if  it  is  felt  for  when  the  abdominal  muscles  are  relaxed.  The 
tumor  is  usually  about  the  size  of  a  small  olive,  and  about  the 
same  shape. 

Prognosis. — With  proper  treatment,  a  great  many  of  these 
cases  can  be  entirely  cured.  If  the  case  has  been  let  go  too  long, 
until  the  baby  is  exhausted  and  has  wasted  away  to  skin  and 
bones,  the  prognosis,  of  course,  is  a  good  deal  worse,  and  many 
will  die  if  they  are  let  go  too  long  without  treatment. 

Treatment. — Medical  treatment  is  of  no  value  in  dealing  with 
these  cases  of  hypertrophic  stenosis  of  the  pylorus.  Surgery  is 
indicated  at  once,  as  soon  as  the  diagnosis  is  made,  and  the 
sooner  the  operation  can  be  done,  the  better  off  the  child  will  be. 
There  are  two  sorts  of  operation  that  may  be  done:  first,  a 
posterior  gastro-enterostomy,  thus  short-circuiting  the  pylorus 
and  letting  the  food  go  through  the  new  opening,  and,  second, 
splitting  the  circular  muscle-fibers  of  the  pylorus.  This  last 
is  considered  the  better  operation,  and  most  of  the  men  are  now 
using  it.  It  takes  only  about  twenty  minutes  to  do,  and  there 
is  very  little  shock  to  the  baby.  The  treatment  both  before  and 
after  operation  is  important.  About  half  an  hour  before  opera- 
tion the  baby's  stomach  should  be  washed  out.  After  the 
operation,  salt  solution  should  be  given  by  rectum  in  order  to 
get  plenty  of  fluid  into  the  baby,  and  it  is  of  great  importance 
not  to  feed  the  baby  very  much  for  a  considerable  time  after 
the  operation,  because  the  intestines  are  so  collapsed  and  atro- 
phic that  the  baby  cannot  digest  the  food.  Breast  milk,  of 
course,  is  the  best  food  to  use  if  it  can  be  obtained,  and  this 
should  be  given  diluted  with  two  parts  of  water,  in  dram  feed- 


PYLORIC   SPASM  93 

ings,  every  hour.  After  the  first  twenty-four  hours  the  amount 
and  strength  of  the  feeding  can  be  gradually  increased.  When 
breast  milk  is  not  available,  the  next  best  thing  is  whey.  When 
it  is  desired  to  increase  the  fat  in  the  feeding,  small  amounts  of 
16  percent  cream  can  be  added.  The  whey  is  given  at  first  in 
dram  feedings  every  hour  and  soon  increased. 

So  much  for  pyloric  stenosis.  It  is  not  a  particularly  common 
condition,  but  important  to  recognize  when  it  is  seen. 

PYLORIC  SPASM 

Pylorospasm  is  a  condition  of  the  pylorus  in  which  there  is 
nervous  spasm,  but  no  organic  stenosis.  It  is  more  common 
than  pyloric  stenosis.  Pylorospasm  is  likely  to  occur  in  babies 
of  rather  nervous  temperament,  who  come  from  nervous  parents. 
The  symptoms  are  very  much  the  same  as  those  in  pyloric  sten- 
osis, but  are  likely  to  be  not  so  severe.  The  difference  is  one  of 
degree  rather  than  of  kind.  Pylorospasm  is  much  more  likely 
to  be  seen  in  bottle-fed  than  in  breast-fed  babies,  whereas  py- 
loric stenosis  occurs  with  equal  frequency  in  breast-  or  bottle- 
fed  babies.  The  vomiting  may  start  immediately  after  birth 
in  pylorospasm,  but  usually  not  until  several  weeks,  or  some- 
times not  until  two  or  three  months,  after  birth,  and  it  is  not  so 
severe  as  in  true  pyloric  stenosis.  The  rest  of  the  symptoms 
are  the  same,  but  not  so  severe  as  in  pyloric  stenosis.  The 
baby  loses  a  great  deal  in  weight :  the  stools  are  small  and  con- 
stipated. The  vomiting  is  Ukely  to  be  not  so  explosive.  The 
stomach  is  usually  not  nearly  so  much  dilated  as  in  true  cases  of 
pyloric  stenosis. 

Physical  Signs. — A  tumor  may  be  felt,  but  the  tumor  is  longer 
and  thinner  than  in  cases  of  stenosis,  and  sometimes  this  tumor 
can  be  felt  contracting  and  relaxing  under  the  finger.  Visible 
peristalsis  is  not  so  common  as  in  true  stenosis.  It  is  usually 
not  difficult  to  decide  that  the  case  is  one  of  stenosis  or  spasm. 
What  it  must  be  differentiated  from  is  simple  indigestion.  That 
is  not  hard.  The  vomiting  in  simple  indigestion  is  not  pro- 
jectile, and  the  symptoms  are  not  so  severe.  There  is  no  evi- 
dence of  indigestion  in  cases  of  pyloric  stenosis  or  spasm.  x-Ray 
examination  after  a  bismuth  meal  is  also  of  value,  as  it  shows 


94  INFANT  FEEDING    (BOSTON  METHODS) 

that  there  is  difficulty  in  the  passage  of  the  food  through  the 
pylorus.  The  trouble  comes  in  differentiating  stenosis  from 
spasm.  How  is  one  to  distinguish  between  these  two  condi- 
tions? 

First  of  all,  spasm  is  rarely  seen  in  breast-fed  babies,  and 
stenosis  may  be  seen  in  both.  The  vomiting  in  spasm  is  likely 
to  start  a  good  deal  later  than  in  stenosis,  and  it  is  not  so  severe 
and  is  not  so  explosive.  The  stools  are  larger  in  spasm  than  in 
stenosis.  A  tumor  may  be  felt  in  both  conditions,  and  in  spasm 
it  is  longer  and  thinner  than  in  stenosis  and  it  may  contract 
under  the  finger.  A  tumor  is  much  more  likely  to  be  felt  in 
stenosis  than  in  spasm.  The  stomach  is  likely  to  be  more  di- 
lated in  stenosis  than  in  spasm.  Visible  peristalsis  is  not  so 
commonly  seen  in  spasm  as  in  stenosis. 

In  mild  cases  of  spasm  the  signs  and  symptoms  of  stenosis, 
such  as  palpable  tumor,  visible  peristalsis,  extremely  explosive 
vomiting,  etc.,  are  not  seen.  In  severe  cases  of  spasm  the  signs 
and  symptoms  may  be  almost  identical  with  those  of  stenosis, 
and  the  differentiation  may  be  impossible.  Severe  cases  of  spasm 
must  be  treated  in  the  same  way  as  cases  of  stenosis. 

Treatment.^A  great  deal  may  be  done  for  some  cases  of 
pylorospasm  by  proper  treatment.  The  most  important  thing 
is  the  regulation  of  the  food  supply.  Breast  milk  is  indicated 
if  it  can  be  obtained.  A  food  low  in  protein  should  be  given, 
adding  sodium  bicarbonate  or  lime-water  to  prevent  the  forma- 
tion of  large  curds,  for  these  pass  a  narrow  pyloric  opening  with 
great  difficulty.  Feed  a  food  low  in  protein  and  fat  and  high 
in  sugar.  Sometimes  hot  applications  to  the  abdomen  before 
the  feeding  are  of  value.  The  drugs  indicated  are  atropin  and 
opium  in  some  form  a  half-hour  before  each  feeding.  Washing 
out  the  stomach  several  times  a  day  with  sodium  bicarbonate  is 
also  of  value.  Sometimes,  no  matter  what  treatment  is  used, 
operation  will  have  to  be  resorted  to.  If  medical  treatment  has 
been  tried  faithfully  for  a  considerable  time  and  the  child  does 
not  get  better,  the  case  must  be  operated  on.  The  operation  is 
the  same  as  for  pyloric  stenosis. 


INTUSSUSCEPTION  95 

INTUSSUSCEPTION 

I  want  to  talk  now  about  intussusception.  What  is  intus- 
susception? Intussusception  is  an  invagination  of  one  part  of 
the  intestine  into  another  part.  This  is  most  Hkely  to  be  an 
ileocecal  invagination,  but  may  occur  in  any  part  of  the  intes- 
tine. It  is  most  often  seen  in  small  babies  and  children,  and  is 
a  very  important  condition  to  recognize  immediately  when  it 
is  seen.  The  etiology  is  rather  obscure.  A  certain  number  of 
cases  will  be  seen  during  the  course  of  a  severe  diarrhea,  and  a 
few  cases  may  be  due  to  trauma.  Some  are  due  to  kinks  or 
malformations  in  the  intestine.  It  is  also  occasionally  seen  in 
severe  cases  of  purpura. 

Symptoms.^ — The  onset  is  usually  sudden.  A  previously 
well  baby  is  taken  with  severe  abdominal  pain  and  vomiting. 
The  stools  consist  of  blood,  mucus,  and  fecal  material.  After 
a  few  stools  have  been  passed  they  no  longer  contain  fecal 
material,  but  only  blood  and  mucus,  and  they  are  small  in 
size.  The  symptoms  become  very  severe,  with  considerable 
shock  and  prostration.  There  may  be  a  fairly  high  tempera- 
ture. In  a  good  many  cases  a  sausage-shaped  tumor  may  be 
felt,  usually  in  the  left  side  of  the  abdomen,  or  if  it  cannot  be 
felt  through  the  abdominal  wall,  it  may  be  felt  by  rectum. 
Sometimes  this  tumor  may  be  seen,  the  intussusception  pro- 
jecting out  of  the  rectum.  In  Dr.  Holt's  series  the  tumor  was 
felt  in  86  percent  of  the  cases. 

Sometimes  the  diagnosis  is  difficult,  especially  in  the  sub- 
acute cases,  where  the  symptoms  are  not  so  marked.  The 
main  thing  intussusception  must  be  distinguished  from  is  in- 
fectious diarrhea,  and  a  good  many  cases  of  intussusception 
are  wrongly  diagnosed  as  infectious  diarrhea.  Infectious  diar- 
rhea does  not  usually  come  on  so  suddenly,  and  in  this  con- 
dition the  abdomen  is  likely  to  be  sunken.  In  intussusception 
it  is  often  distended.  One  cannot  tell  much  from  the  stools, 
because  they  may  look  very  much  the  same  in  both  conditions. 
The  temperature  is  likely  to  be  higher  in  infectious  diarrhea  than 
in  intussusception.  Not  much  can  be  told  from  the  condition 
of  the  child,  because  it  may  be  extremely  prostrated  in  both 
conditions;    but    usually  there   is    more   shock   in   intussus- 


96  INFANT   FEEDING    (BOSTON  METHODS) 

ception — it  is  not  so  likely  to  be  in  most  cases  of  infectious 
diarrhea. 

Treatment. — Operation  right  away!  As  soon  as  a  diagnosis 
of  intussusception  is  made,  call  in  a  surgeon  and  have  him  oper- 
ate immediately.  Often  a  delay  of  six  or  eight  hours  in  operat- 
ing will  cost  the  life  of  the  child,  because  the  operation  should  be 
done  when  the  child  is  in  as  good  condition  as  possible.  It  is 
true  that  some  cases  of  intussusception  will  reduce  themselves 
spontaneously,  and  that  others  may  be  reduced  by  the  injec- 
tion of  water  into  the  bowel.  This  is  altogether  too  uncertain 
to  be  depended  upon,  however.  The  prognosis  is  not  a  good 
one.  In  about  50  percent  of  the  cases  the  child  dies.  The 
prognosis  depends,  more  than  anything  else,  upon  how  soon  the 
child  is  operated  upon  after  the  diagnosis  is  made. 

The  following  three  histories,  taken  from  the  Children's 
Hospital  records,  may  serve  to  give  you  a  better  idea  of  the 
symptoms: 

Case  1. — C.  O.,  seven  years.  Five  days  ago  an  eruption  was 
noticed  on  legs  and  thighs,  which  was  composed  of  areas  the 
size  of  the  tip  of  the  little  finger,  level  with  the  skin  and  of  a 
purplish  color  at  first,  changing  to  brownish  red. 

These  spots  faded  slowly  and  disappeared  almost  entirely  in 
three  days.  At  this  time  the  legs  and  feet  were  swollen  (typical 
purpura). 

Two  days  ago  a  diarrhea  began,  which  was  composed  entirely 
of  fecal  matter  at  first,  but  in  a  few  hours  was  practically  all 
blood,  very  little  mucus,  and  no  fecal  matter.  Has  been  vom- 
iting a  great  deal  of  greenish-yellow,  liquid  mucus,  occasionally 
blood  streaked.     Moderate  pain  in  the  right  abdomen. 

Hasty  examination  shows  a  large  tumor  in  right  lower  quad- 
rant. Abdomen  distended  and  tympanitic;  general  condition 
fair.    Transferred  surgical  and  operated.    Intussusception  found. 

Case  2. — D.  M.,  eighteen  months.  (Illustrating  the  subacute 
type  of  case.)  Three  weeks  ago  the  child  fell  from  a  chair  to 
the  floor.  His  father  says  that  when  he  picked  up  the  baby  he 
felt  a  lump  on  the  abdomen  which  soon  afterward  disappeared. 
The  child  played  and  acted  normally  the  rest  of  the  day,  but 
that  night  began  to  vomit.     A  doctor  was  called,  and  after  he 


INTUSSUSCEPTION  97 

had  taken  a  rectal  temperature  the  baby  passed  some  blood  and 
mucus.  An  enema  given  immediately  afterward  gave  no  re- 
sults. Since  then  he  has  vomited  occasionally.  The  stools 
are  dark,  with  some  mucus  and  blood. 

One  week  ago  he  had  another  more  severe  vomiting  attack. 
Bowels  have  moved  twice  daily  for  the  past  week— dark  in 
color.  No  blood  noted.  One  day  ago  the  stool  was  dark,  with 
streaks  of  fresh  blood.  Today  he  had  four  stools,  dark  in  color, 
with  considerable  mucus,  but  no  blood. 

Has  been  vomiting  all  day  and  has  complained  of  pain  in 
stomach  region. 

P.  E.:  In  fair  general  condition.  Abdomen:  Full,  rounded, 
tense,  tympanitic;  muscular  resistance  is  general,  but  more 
marked  on  left  side.  Some  tenderness  on  left.  No  tumor  felt. 
Rectal  negative. 

Day  After  Admission. — Child  has  appeared  fairly  comfort- 
able since  admission,  but  has  complained  of  moderate  abdominal 
pain  at  times.  Has  vomited  all  food  taken.  One  stool  ob- 
tained contained  mucus  and  blood.  P.  E. :  In  the  abdomen  is 
felt  a  definite,  sausage-shaped  tumor  in  left  iliac  region. 

Rectal  examination  shows  resistance  on  left. 

Transferred  surgical — operated,  and  intussusception  found. 

Case  3. — R.  M.,  seven  months.  Eight  days  ago  he  began  to 
draw  up  his  knees  and  scream.  A  doctor  who  was  summoned 
called  it  "stoppage  of  the  bowels."  He  administered  a  sup- 
pository without  result.  He  then  gave  an  enema  and  got  a 
stool.     Castoria  was  then  given  and  normal  stools  followed. 

Three  nights  ago  he  began  to  vomit.  He  vomited  ten  times 
during  the  next  day  and  has  vomited  frequently  since — not 
projectile,  no  bile  or  blood.  Last  vomitus  was  at  1.15  this 
afternoon.  This  "looked  and  smelled  like  a  bowel  move- 
ment." Bowels  moved  five  times  yesterday  and  at  2.30  this 
morning.  No  blood  in  stools.  Mucus  in  stools  yesterday  and 
the  one  this  morning  was  mostly  mucus  containing  a  little  fecal 
matter. 

P.  E. :  In  good  condition.  Abdomen  negative.  Rectal  nega- 
tive. Next  day  vomited  continuously  all  day;  twice  had  fecal 
vomiting. 

Transferred  surgical  and  operated.     Intussusception  found. 
7 


98  INFANT  FEEDING    (BOSTON  METHODS) 

Acroosis 

Acidosis  is  a  condition  which  has  been  discussed  a  great  deal 
of  late;  many  investigators  are  working  on  problems  connected 
with  it;  but  its  causation  and  exact  nature  are  still  very  im- 
perfectly understood.  I  can  hope  to  do  no  more  than  give  you 
a  very  superficial  view  of  this  complicated  subject,  and,  as  I 
said  before,  when  discussing  the  diarrheas  of  infancy,  it  is  hardlj^ 
fair  to  speak  dogmatically  in  discussing  such  a  subject;  but  I 
shall  do  so  for  the  sake  of  clearness. 

What  is  acidosis?  Normally  the  blood  is  slightly  alkaline  in 
reaction.  This  alkalinity  is  maintained  in  the  body  by  a  num- 
ber of  factors.  When  the  degree  of  alkalinity  becomes  lessened 
and  the  blood  more  nearly  approaches  a  neutral  reaction,  a 
condition  of  acidosis  results.  Acidosis  is  thus  a  diminution  of 
the  alkalinity  in  the  blood. 

What  may  cause  a  diminution  of  the  alkalinity  of  the  blood? 
First  of  all,  there  may  be  an  increased  acid  production,  such  as 
occurs  in  diabetes  or  in  starvation.  This  increased  production 
of  acids  occurs  when  fat  is  being  broken  down  in  the  body,  es- 
pecially when  carbohydrate  food  is  withdrawn  and  the  fat 
supply  of  the  body  is  broken  down  and  imperfectly  oxidized. 
These  "acid  bodies,"  as  they  are  called,  are  acetone,  diacetic 
acid,  and  betaoxybutyric  acid. 

Another  way  in  which  acidosis  is  produced  is  by  a  decrease  in 
add  elimination.  The  normal  acidity  of  the  urine  is  due  to 
acid  sodium  phosphate  in  solution.  If  there  is  no  excretion  or 
very  little  excretion  of  this  substance,  due  to  anuria,  and  it  is 
retained  in  the  body,  it  tends  to  produce  acidosis.  This  con- 
dition may  occur  in  the  diarrheal  diseases  of  infants  when  there 
is  anuria. 

A  loss  of  alkali  from  the  body  may  help  to  produce  acidosis. 
This  may  occur  in  fermentative  diarrhea,  where  there  is  a  tre- 
mendously acid  condition  in  the  intestine.  The  alkali  reserve 
of  the  body  is  drawn  upon  to  neutralize  this  acidity,  and  a  large 
amount  of  alkali  may  be  lost  in  the  stools  in  this  way.  These 
three  causes  may  singly  or  together  produce  acidosis. 

As  Dr.  Marriott,  of  Johns  Hopkins,  has  said,  "acidosis"  is  a 
term  which  is  used  very  loosely.     It  is  used  by  most  people  to 


ACIDOSIS  99 

indicate  that  a  child  has  acetone  or  diacetic  acid  in  the  urine. 
Strictly  speaking,  it  is  true  that  a  mild  acidosis  is  present  when 
these  substances  are  found  in  the  urine,  but  they  will  be  found  in 
the  urines  of  many  children  who  have  no  clinical  signs  of  acido- 
sis, and  should  be  looked  upon  rather  as  a  symptom  than  as 
anything  else,  and  no  treatment  is  indicated,  nor  is  there  cause 
for  worry  unless  clinical  symptoms  of  acidosis  are  present  in 
addition  to  the  presence  of  acetone  in  the  urine.  li  is  surpris- 
ing, in  a  routine  examination  of  the  urines  from  many  sick 
children,  to  see  how  many  of  these  contain  acetone.  Ace- 
tonuria  may  be  regarded  in  much  the  same  way  as  fever  is: 
we  do  not  need  to  worry  about  fever  unless  it  is  excessive:  we 
do  not  need  to  worry  about  acetonuria  unless  it  is  severe  and 
has  other  symptoms  of  acidosis  along  with  it.  Acetone  will  be 
found  in  the  urines  of  most  children  ill  with  acute  fevers.  What 
are  the  tests  for  acetone  and  diacetic  acid  in  the  urine?  They 
are  both  simple. 

Tests  for  Acetone  and  Diacetic  Acid  in  Urine. — Acetone. — To 
5  c.c.  of  urine  in  a  test-tube  add  a  small  crystal  of  sodium 
nitroprussid  and  a  few  drops  of  strong  acetic  acid,  and  shake. 
Make  alkaline  with  ammonium  hydroxid.  A  purple  color  indi- 
cates acetone. 

Diacetic  Add. — To  5  c.c.  of  urine  in  a  test-tube  add  an  excess 
of  a  10  percent  solution  of  ferric  chlorid.  A  dark  brownish-red 
color  indicates  diacetic  acid.  After  the  taking  of  certain  drugs, 
especially  aspirin,  such  a  reaction  may  be  obtained  in  the  urine, 
and  the  color  does  not  disappear  on  heating.  The  red  color,  if 
due  to  diacetic  acid,  disappears  on  heating. 

In  What  Conditions  is  Acetone  Likely  to  be  Found  in  the 
UrmQl— Starvation.— ^Yien  a  person  takes  little  or  no  food  for 
a  day  or  two,  there  is  likely  to  be  acetone  in  the  urine,  due  to 
the  breaking  down  of  the  body  fat  which  is  being  used  for  food. 
This  is  probably  one  reason  why  acetone  is  so  often  found  in 
the  urines  of  fever  patients:  they  eat  very  little.  This  type  of 
acetonuria  is  also  likely  to  be  seen  after  surgical  operations 
upon  children ;  whether  it  depends  upon  starvation  alone,  or 
whether  other  factors  as  well  enter  into  its  production,  is  not 
certain. 

Diabetes.— Acetone  and  diacetic  acid  occur  very  frequently 


100  INFANT   FEEDING    (BOSTON   METHODS) 

in  the  urines  of  diabetic  patients,  as  you  all  know.  This  is 
probably  due  to  the  breaking  down  of  ingested  or  body  fat. 

Fever. — Acetone  is  Ukely  to  occur  in  the  urine  of  a  patient 
with  anj'^  febrile  disease.  Whether  this  is  due  to  the  fact  that 
these  patients  eat  little,  or  whether  it  may  be  due  to  some  pe- 
culiar effect  of  fever  on  the  body  metabolism,  is  not  certain. 

The  three  types  of  acetonuria  that  we  have  been  speaking  of 
are  not  pecuUar  to  childhood — they  do  not  interest  us  particu- 
larly. 

Types  of  Acidosis  Peculiar  to  Children. — Diarrhea. — There 
may  be  an  acidosis  accompanying  certain  diarrheas  of  infancy. 

"Recurrent"  Vomiting. — In  cases  of  so-called  recurrent  vom- 
iting in  children  there  is  usually  acetone  in  the  urine,  and  some- 
times other  evidences  of  acidosis.  In  some  cases  this  is  prob- 
ably present  secondary  to  the  vomiting,  and  is  due  to  the  fact 
that  the  child  eats  nothing;  in  others  it  may  be  primary,  and 
the  vomiting  be  due  to  acid  intoxication,  the  whole  disturbance 
being  caused  by  some  peculiar  derangement  of  metabohsm  of 
which  we  know  little. 

Severe  Acid  Intoxication;  "  Epidemic  "  or  Periodic. — Let  me  say 
at  the  start  that  there  is  really  no  such  thing  as  true  epidemic 
acidosis.  There  is  a  severe  acidosis  which  occurs  in  epidemics 
secondary  to  influenza  or  other  nasopharyngeal  or  respiratory 
infection,  but  the  epidemic  is  not  of  "acidosis"  itself.  This  is 
the  most  interesting  type  of  acidosis,  the  most  severe,  and  the 
one  which  I  want  to  talk  of  particularly. 

How  is  one  to  tell,  when  acetone  is  found  in  the  urine,  whether 
or  not  the  condition  is  severe  enough  to  worry  about  or  to  call 
for  any  particular  treatment?  The  amount  of  acetone  and 
diacetic  acid  in  the  urine  is  not  a  good  index  of  the  severity  of 
the  acidosis,  for  severe  acidosis  may  occur  with  very  little  ace- 
tone in  the  urine,  or  mild  acidosis  with  a  good  deal  of  acetone 
in  the  urine.  There  are  a  number  of  methods  of  determining 
the  degree  of  acidosis  and  expressing  it  quantitatively,  the  two 
most  important  of  which  are  analyses  of  the  alveolar  air  and  of 
the  blood  itself.  I  merely  mention  these,  as  they  are  hardly 
practical  for  the  average  physician  to  use. 

For  practical  purposes,  if  a  child  has  acetone  and  diacetic 
acid  in  the  urine,  is  restless  and  vomits,  and  has  deep,  labored 


ACIDOSIS  101 

breathing  without  cyanosis,  one  may  decide  that  there  is  acidosis 
present  and  start  immediate  treatment. 

Certain  children  seem  to  be  subject  to  periodic  attacks  of  acid 
intoxication,  and  may  have  an  attack  every  few  months.  I 
well  recall  one  child  of  five  who  was  in  the  Children's  Hospital 
with  acidosis  six  times  in  ten  months.  She  was  extremely  sick 
in  each  attack,  with  identical  symptoms  each  time  she  entered. 
These  periodic  attacks  of  acid  intoxication  are  similar  to  the 
"epidemic"  cases. 

What  is  the  etiology  of  the  condition?  Some  of  the  cases 
seem- to  be  secondary  to  acute  indigestion,  some  secondary  to 
exhaustion  or  severe  nervous  disturbance;  the  child's  equihb- 
rium  is  very  unstable,  and  its  body  chemistry  can  be  easily  up- 
set. It  is  difficult  to  explain  the  epidemic  cases  on  any  other 
basis  than  that  of  an  infection — the  epidemic  in  Boston  last 
spring  occurred  when  there  was  a  great  deal  of  respiratory  in- 
fection of  various  sorts  about,  and  in  many  of  the  cases  the  ton- 
sils or  nasopharynx  was  inflamed  and  swollen.  Personally,  I 
believe  that  this  epidemic  type  of  acidosis  is  secondary  to  some 
infection  of  the  tonsils  or  nasopharynx,  probably  with  the  in- 
fluenza bacillus  or  the  streptococcus. 

The  usual  story  of  a  case  is  about  as  follows: 

A  child  is  taken  rather  suddenly  with  uncontrollable  vomit- 
ing— it  may  or  may  not  have  had  a  slight  fever  with  naso- 
pharyngitis previously.  There  is  usually  no  diarrhea.  The 
skin  is  dry  and  hot,  with  moderate  fever;  the  abdomen  is 
sunken,  and  if  the  condition  goes  on,  the  eyes  may  be  sunken, 
due  to  the  loss  of  fluid  from  the  vomiting,  which  is  very  severe 
and  may  be  uncontrollable :  usually  nothing  can  be  kept  on  the 
stomach.  The  urine  is  very  scanty  and  highly  colored,  and  is 
loaded  with  acetone  and  diacetic  acid.  There  is  Hkely  to  be 
excessive  thirst.  The  lips  are  of  a  bright,  cherry-red  color; 
this  is  quite  a  striking  characteristic  of  the  condition.  The 
respiration  is  deep,  rapid,  and  labored,  without  cyanosis,  and 
there  is  a  peculiar  sweetish  odor  to  the  breath — the  odor  of 
acetone.     The  child  may  be  very  restless  or  may  be  in  a  stupor. 

These  children  are  extremely  sick,  their  condition  is  a  precarious 
one,  and  vigorous  and  prompt  treatment  is  indicated. 

Treatment. — Nursing. — An  extremely  important  part  of  the 


102  INFANT   FEEDING    (BOSTON   METHODS) 

treatment  is  to  have  a  good  nurse,  or  an  intelligent,  capable 
mother,  who  can  be  with  the  child ;  these  children  need  to  have 
constant  attention. 

Catharsis. — If  the  child  can  retain  anything  on  the  stomach, 
give  it  a  cleaning  out  with  calomel  or  castor  oil;  if  it  cannot, 
empty  the  intestine  from  below  with  a  suds  enema. 

Soda. — Whether  or  not  the  child  recovers  depends  a  great 
deal  upon  whether  enough  alkali  can  be  gotten  into  it  to  neutral- 
ize the  acidosis  and  to  bring  back  the  blood  to  a  normal  alkahn- 
ity.  If  the  urine  can  be  made  alkaline  in  the  first  twenty-four 
hourS;  the  child  will  probably  get  well;  if  it  cannot  be,  it  may 
get  well  or  may  die.  This  is  where  a  good  nurse  comes  in — she 
must  be  at  the  child  every  minute  to  get  it  to  take  alkali.  The 
alkali  may  be  given  by  mouth,  intravenously,  or  by  rectum. 
You  will  not  in  most  cases  be  able  to  depend  upon  getting  it 
into  the  child  by  mouth,  as  the  vomiting  is  so  severe,  but  mouth 
administration  should  be  tried  at  first.  The  dosage  depends 
upon  the  size  of  the  child  and  the  severity  of  the  acidosis,  but 
should  always  be  liberal.  Thirty  grains  every  two  hours  to  a 
child  of  three  years  is  not  too  much.  If  it  has  to  be  given  by 
rectum,  30  drops  a  minute  of  a  10  percent  solution  is  suitable. 
If  it  is  given  intravenously,  a  4  percent  solution  is  used,  and  the 
amount  to  be  injected  depends,  of  course,  upon  the  size  of  the 
child. 

Sodium  bicarbonate  should  not  be  given  subcutaneously  as 
it  causes  sloughing.  Do  not  give  too  much  soda;  there  is  reason 
in  everything,  and  I  have  seen  a  child  who  died  more  from  too 
much  soda  than  from  acidosis. 

Fluid. — It  is  of  extreme  importance  to  get  plenty  of  fluid  into 
children  with  acidosis,  to  prevent  them  from  getting  dried  out, 
and  to  keep  the  kidneys  active,  to  remove  acid  from  the  system. 
They  are  usually  very  thirsty.  A  scanty  urinary  secretion  is 
a  bad  sign.  Fluid  is  best  given  subcutaneously  in  the  form 
of  normal  salt  solution. 

Food. — Next  in  importance  is  food.  The  stomach  is  so  irri- 
table that  it  is  probable  that  little  food  will  be  retained  at  first. 
It  is  useless  to  try  to  give  solid  food.  The  best  food  is  skimmed 
milk,  with  dextrose  added  to  10  percent.  Dextrose  is  indicated 
in  acidosis  in  the  same  way  it  is  in  diabetic  coma:  if  easily  avail- 


ACIDOSIS  103 

able,  carbohydrate  can  be  furnished  to  the  body:  it  tends  to 
stop  the  pathological  breaking  down  of  fat  and  acid  production. 
Dextrose,  if  not  well  borne  by  the  stomach,  may  be  given  in- 
travenously in  a  2  percent  solution,  subcutaneously  in  a  5  per- 
cent solution,  or  by  rectum  in  a  10  percent  solution. 

As  convalescence  progresses  the  food  should  be  largely  car- 
bohydrate in  character,  with  very  little  fat. 

Opium. — Opium  in  some  form,  usually  morphin  subcutane- 
ously, should  be  given  up  to  the  limit  of  tolerance,  as  one  of  the 
most  desirable  things  in  treatment  is  to  stop  the  vomiting  if 
possible  and  to  quiet  the  restlessness,  which  may  be  extreme. 

Stimulants. — If  stimulants  are  needed,  caffein  or  camphor  in 
oil  may  be  used. 

This  condition  is  an  extremely  severe  one,  but  a  good  deal 
can  be  done  for  it  by  prompt  and  thorough  treatment. 


LECTURE  Vn 

RICKETS— SCURVY— SPASMOPHILIA 

I  shall  speak  today  of  three  diseases  of  metabolism :  rickets, 
scurvy,  and  spasmophiHa,  or  tetany. 

RICKETS  (RACHITIS) 

Definition. — Rickets  is  a  constitutional  disease,  probably 
caused  mostly  by  prolonged  error  in  diet,  bringing  about  a  faulty 
metabolism.     Its  chief  manifestations  are  in  the  bones. 

Pathology. — The  chief  lesions  of  rickets  are  in  the  bones. 
There  is  an  overgrowth  and  softening  of  the  cartilaginous  layer 
between  the  epiphysis  and  shaft  of  the  long  bones.  This  area 
is  markedly  hyperemic,  from  the  ingrowth  of  small  blood- 
vessels, and  the  deposition  of  lime  salts  is  much  decreased  in 
both  the  epiphyses  and  shafts  of  the  bone,  thus  resulting  in 
delayed  ossification  and  soft  bone. 

The  outer  layers  of  the  shaft  of  the  bone  are  thick,  soft,  and 
hyperemic,  with  a  lessened  deposition  of  lime,  and  the  centers  of 
ossification  in  the  epiphyses  of  the  bone  are  in  the  same  con- 
dition. 

The  essential  thing  to  remember  is  that  there  is  not  enough 
lime  deposited  in  the  bone,  and  this  results  in  a  soft  bone,  which 
is  easily  distorted  in  shape  or  actually  broken.  Rickets  may 
last  anywhere  from  three  to  twelve  months,  the  process  in  the 
bone  going  through  several  stages,  resulting  in  a  permanent 
enlargement  at  the  epiphyses,  with  or  without  a  deformed  shaft. 

Let  it  be  distinctly  understood  that  many  children  one  sees 
with  rachitic  deformities,  such  as  bow-legs,  enlarged  epiphyses, 
etc.,  have  not  actual  rickets — the  rachitic  process  may  have  en- 
tirely subsided,  and  what  is  seen  is  the  end-result  of  the  process. 
In  many  cases  a  child  who  has  had  severe  rickets  may  be  left 
with  little  or  no  deformity. 

104 


RICKETS — SCURVY — SPASMOPHILIA  105 

Etiology. — The  etiology  of  rickets  is  probably  due  to  a  num- 
ber of  factors. 

It  is  much  more  likely  to  be  seen  in  artificially  fed  babies  than 
in  breast  fed;  it  is  most  likely  to  be  seen  between  the  sixth  and 
eighteenth  months,  but  may  be  seen  before  or  after  this.  It  is 
much  more  common  in  the  thickly  populated  districts  of  large 
cities  than  it  is  in  the  country,  and  negroes  and  Italians  seem  to 
b.e  particularly  prone  to  it.  It  is  especially  likely  to  be  seen  in 
children  who  have  had  a  good  many  digestive  troubles,  who 
have  never  seemed  able  to  do  well  as  regards  their  feeding,  and 
who  have  been  tried  first  on  one  food,  then  on  the  other,  es- 
pecially the  proprietary  foods.  The  end-result  of  all  these 
conditions  is  that  not  enough  calcium  is  deposited  in  the  bones, 
and  this  is  one  particular  thing  that  the  various  theories  of  the 
etiology  of  rickets  try  to  explain.  All  cases  cannot  be  due  to  a 
lack  of  calcium  in  the  food,  for  most  babies  fed  on  modifications 
of  cow's  milk  ingest  three  or  four  times  as  much  calcium  as  is 
actually  necessary  for  them.  It  must,  therefore,  be  due  to  a 
faulty  assimilation  of  calcium.  How  can  this  be  brought  about? 
One  way  that  it  can  certainly  be  brought  about  is  by  an  in- 
tolerance for  fat,  where  a  large  amount  of  the  higher  fatty  acids 
are  present  in  the  intestine;  the  calcium  in  the  food  combines 
with  these  acids  to  form  insoluble  calcium  soaps,  which  cannot 
be  absorbed  and  are  excreted  in  the  feces,  thus  resulting  in  a 
great  loss  of  calcium.  Another  cause  is  the  taking  of  a  food 
which  contains  too  little  calcium,  as  a  very  weak  breast  milk 
or  a  dilute  condensed  milk  formula.  Personally,  I  believe  that 
most  cases  of  rickets  can  be  explained  by  one  or  the  other  of 
these  errors  in  diet. 

For  practical  purposes,  leaving  all  theory  aside,  we  can  say 
that  rickets  is  caused  by  faulty  hygiene  and  poor  nutrition. 

Symptoms  and  Signs. — These  are  fairly  characteristic,  though 
at  the  outset  they  may  be  rather  indefinite.  The  baby  may  be 
irritable,  may  not  gain  in  weight,  may  be  especially  restless  at 
night,  and  may  sweat  a  good  deal  about  the  head.  When  the 
disease  is  developed,  it  is  absolutely  unmistakable.  The  head 
in  rickets  is  likely  to  be  square,  with  very  prominent  frontal 
bones.  The  anterior  fontanel  closes  a  good  deal  later  than  it 
should.     Normally,  the  fontanel  closes  at  about  the  nineteenth 


106  INFANT   FEEDING    (BOSTON   METHODS) 

month;  in  rickets,  usually  a  good  deal  later.  There  may  be 
soft  spots  in  the  skull,  called  "craniotabes."  The  sutures  of 
the  skull  may  remain  open  a  good  deal  longer  than  usual.  The 
dentition  is  usually  delayed:  a  baby  of  eighteen  months  may 
have  only  as  many  teeth  as  a  baby  of  eight  or  ten  months. 

The  chest  may  be  flattened  laterally,  giving  the  so-called 
"Harrison's  grooves,"  a  concavity  of  the  ribs  on  the  sides  in- 
stead of  a  convexity.  Or,  in  some  cases,  you  may  have  seeui 
the  "pigeon-breasted"  chest,  with  the  sternum  very  prominent. 
A  characteristic  thing,  pathognomonic  of  rickets,  is  the  so- 
called  "rosary,"  which  is  a  beading  of  the  ribs  due  to  enlarge- 
ment at  the  junction  of  the  ribs  and  costal  cartilages.  These 
nodules  may  be  as  small  as  peas  or  as  large  as  marbles. 

The  changes  in  the  long  bones  also  are  important;  there 
may  be  a  great  deal  of  bowing  of  the  bones  of  the  arms  and  also 
of  the  legs,  which  sometimes  may  be  extreme  in  the  more  severe 
cases.  The  epiphyses  at  the  wrist  are  usually  enlarged,  as  are 
those  at  the  ankles  and  knees.  There  may  be  a  severe  kyphosis 
of  the  spine  in  a  good  many  cases.  The  clavicles  also  may  be 
tremendously  deformed.  There  may  be  in  many  of  the  long 
bones  multiple  fractures,  due  to  the  extreme  softness. 

General  Appearance. — The  children  are  usually  small,  poorly 
nourished,  underdeveloped  in  every  way.  The  abdomen  is 
prominent,  and  the  umbilicus  is  often  everted.  The  spleen  and 
liver  are  enlarged.  These  children  are  usually  anemic,  some- 
times to  an  extreme  degree,  and  are  irritable  and  nervous. 
Laryngismus  stridulus  or  spasmophilia  may  be  associated  with 
rickets. 

Diagnosis. — The  diagnosis  is  not  at  all  difficult;  an  extreme 
case  can  hardly  be  mistaken  for  anything  else.  The  stage  of 
the  process  may  be  told  by  the  appearance  of  the  bones  as  shown 
by  the  a:-ray. 

Treatment. — The  treatment  of  rickets  consists  mainly  of 
hygiene,  sunlight,  fresh  air,  and  proper  feeding.  More  can  be 
accomplished  by  this  method  of  treatment  than  by  any  other. 
It  is  a  question  whether  or  not  drugs  do  any  good;  the  drugs 
usually  given  are  phosphorus  and  cod-liver  oil.  I  do  not  be- 
lieve in  giving  the  latter,  because  the  fat  digestion  is  usually  so 
poor.     Phosphorus  may  do  some  good,  as  it  has  been  shown  that 


RICKETS — SCURVY — SPASMOPHILIA  107 

the  administration  of  phosphorus  to  rachitic  children  favors  the 
retention  of  calcium.  The  dose  of  phosphorus  for  a  baby  is 
T^^  grain,  given  from  one  to  three,  times  a  day.  It  may  be 
given  in  the  form  of  pills,  or  as  the  "phosphorated  oil"  of  the 
pharmacopeia,  a  minim  of  which  contains  about  rfr  grain  of 
phosphorus.  Iron  is  indicated  if  the  children  are  anemic,  and 
the  best  preparation  to  use  is  the  saccharated  oxid  of  iron,  or 
"Eisenzucker,"  as  it  is  sometimes  called.  This  may  be  given 
in  doses  of  three  grains  three  times  a  day  to  babies  a  year 
old. 

The  treatment  of  the  deformities  of  rickets  is,  of  course, 
orthopedic. 

Rickets  is  a  disease  that  does  not  in  itself  threaten  life.  The 
two  worst  things  about  it  are  that  babies  with  rickets  have  very 
little  resistance  to  infection,  especially  pulmonary  infection, 
and  that  in  many  cases  permanent  deformities  result  from  the 
rachitic  process. 

SCURVY 

Scurvy  is  the  next  subject  we  take  up.  Infantile  scurvy  is  the 
same  disease  as  scurvy  in  the  adult.  It  is  not  the  same  disease 
as  rickets,  and  has  nothiilg  to  do  with  it,  although  years  ago 
cases  of  scurvy  used  to  be  called  "acute  rickets."  It  is  often 
associated  with  rickets,  however,  in  about  half  the  cases. 

Scurvy  is  a  food  disease.  It  may  be  defined  as  a  disease  of 
metabolism  dependent  on  some  prolonged  deficiency  in  the 
diet,  the  chief  manifestation  of  which  is  hemorrhage,  especially 
under  the  periosteum  of  the  long  bones  of  the  leg.  It  is  usually 
seen  in  babies  from  six  to  sixteen  months  of  age. 

A  great  many  cases  of  scurvy  will  be  found  among  babies  fed 
on  pasteurized  or  sterilized  milk  or  on  proprietary  foods.  It 
does  not  often  develop  in  children  fed  on  raw  milk  or  on  the 
breast.  The  reason  probably  is  that  the  development  of  scurvy- 
depends  on  the  absence  of  vitamins  in  the  diet.  These  are 
chemical  substances  in  the  milk  necessary  for  the  baby  to  have, 
but  which  are  destroyed  by  heat.  Therefore,  the  boiUng  of 
milk  destroys  the  vitamins  and  predisposes  to  the  development 
of  scurvy.  However,  the  etiology  is  not  entirely  clear.  There 
are  a  great  many  contradictory  features  in  the  etiology  of  the 


108  INFANT   FEEDING    (BOSTON  METHODS) 

disease,  for  scurvy  may  develop  in  babies  fed  on  raw  milk  or 
on  breast  milk. 

A  number  of  years  ago  the  American  Pediatric  Society  m- 
vestigated  a  large  series  of  cases  of  scurvy,  with  special  regard 
to  the  etiology,  and  the  only  definite  conclusion  that  they  could 
arrive  at  was  that  the  more  a  food  differs  from  a  baby's  natural 
food,  breast  milk,  the  more  hkely  is  its  use  to  be  followed  by 
scurvy. 

A  tabulation  of  the  cases  they  investigated  is  as  follows: 

12  cases  fed  on  breast  milk. 


5 

20 

60 

107 

214 


"  raw  cow's  milk. 

"  pastem"ized  milk. 

"  condensed  milk. 

"  sterilized  milk. 

"  proprietary  infant  foods. 


You  can  see  from  this  that  scurvy  viay  develop  in  a  baby 
fed  on  any  sort  of  milk,  but  that  it  is  much  more  hkely  to  be 
seen  in  babies  who  have  been  fed  on  sterilized  milk  or  on  one 
of  the  proprietary  foods.  We  do  not  need  to  go  into  the  etiol- 
ogy of  scurvy  any  further;  it  is  enough  for  our  purposes  to  say 
that  it  is  probably  caused  in  most  cases  by  feeding  a  baby  on  a 
prolonged  diet  which  lacks  some  element  or  elements  necessary 
for  its  proper  nutrition:  that  these  elements  probably  are 
"vitamins"  and  are  destroyed  by  heat,  which  explains  why 
babies  are  so  much  more  hkely  to  develop  scurvy  when  they 
are  fed  on  sterilized  rather  than  on  raw  milk. 

Pathology. — The  most  prominent  feature  in  the  pathology  of 
scurvy  is  the  tendency  to  hemorrhage.  This  hemorrhage  oc- 
curs especially  under  the  periosteum  of  the  bones,  and  is  much 
more  often  seen  in  the  bones  of  the  lower  extremities  than  in 
any  other  location.  Sometimes  the  hemorrhage  may  be  very 
large,  and  may  cause  tremendous  swelling  of  the  legs;  the 
clotted  or  partly  organized  blood  may  feel  very  hard,  and  may 
sometimes  be  mistaken  for  a  bony  tumor.  Although  there  may 
be  considerable  hemorrhage  under  the  periosteum  adjacent  to  a 
joint,  the  joints  themselves  are  but  very  rarely  affected.  There 
may  be  hemorrhage  from  the  kidneys,  or  more  rarely  into  the 
skin,  into  the  intestine,  or  back  of  the  eyeball.  A  hemorrhagic 
condition  of  the  gums,  especially  the  upper  gums,  is  common. 


RICKETS — SCURVY — SPASMOPHILIA  lOQ 

Symptoms.— The  symptoms  of  scurvy  are  fairly  character- 
istic. The  onset  is  usually  gradual,  and  the  first  symptom  is 
likely  to  be  tenderness  of  the  legs.  The  usual  story  is  about 
this:  a  baby  who  has  been  previously  well,  and  who  perhaps 
has  been  walking  about,  becomes  fretful  and  irritable,  stops 
walking,  and  cries  when  its  legs  are  moved  or  touched.  In 
many  early  cases  these  may  be  the  only  symptoms,  and  sUght 
as  these  symptoms  may  seem,  they  are  enough  upon  which  to 
make  a  positive  diagnosis  of  scurvy,  provided  other  conditions  are 
ruled  out.  There  may  be  a  great  deal  of  swelling  of  the  legs, 
and  they  are  usually  extremely  tender,  the  sHghtest  touch  caus- 
ing the  baby  severe  pain.  The  position  these  babies  lie  in  is 
characteristic,  with  outward  rotation  of  the  thighs  and  eversion 
of  the  feet.  The  appearance  of  the  gums  is  characteristic: 
in  babies  who  have  teeth  the  gums  around  the  teeth,  especially 
the  upper  ones,  are  swollen,  soft,  dark  reddish  purple  in 
color,  and  bleed  very  easily.  Blood  may  occur  in  the  urine  in 
some  cases — sometimes  it  may  be  the  first  symptom:  the 
urine  may  be  bright  red,  or  it  may  be  recognized  by  microscopic 
examination.  If  a  small  baby  has  blood  in  its  urine,  scurvy 
should  always  be  considered.  The  pain,  the  tenderness  and 
sweUing  of  the  legs,  the  purple,  swollen  gums,  and  the  hema- 
turia are  the  most  important  points  in  the  diagnosis  of  scurvy. 
Of  these,  pain  in  the  legs  is  the  most  important  symptom. 
All  these  signs  may  not  occur  together,  but  when  they  do,  the 
diagnosis  of  scurvy  is  very  easy  to  make. 

Rarely  there  may  be  hemorrhages  into  the  skin  and  into  the 
intestine,  or  in  the  orbit,  causing  a  protrusion  of  the  eyeball, 
but  these  are  not  the  ordinary  signs  to  be  looked  for. 

There  is  usually  no  particular  digestive  disturbance  with 
scurvy.     There  may  be  fever,  in  most  cases  not  very  high. 

Prognosis. — If  the  case  is  not  treated  and  lingers  on  for  several 
months,  the  child  will  finally  die  from  toxemia  and  malnutri- 
tion; if  it  is  treated  right,  it  will  be  well  in  a  few  days. 

Diagnosis. — There  are  a  number  of  things  from  which  scurvy 
must  be  differentiated.  One  of  the  most  common  mistakes  is 
to  call  scurvy  acute  rheumatism.  These  points  should  help  in 
the  diagnosis.  Acute  rheumatism  is  excessively  rare  in  chil- 
dren under  two  or  three  years  old;  in  scurvy  the  other  signs, 


110  INFANT  FEEDING    (BOSTON  METHODS) 

sponginess  of  the  gums,  etc.,  are  likely  to  be  present,  and  the 
swelling  and  tenderness  are  especially  in  the  shaft  of  the  bone, 
and  not  around  the  joint,  as  they  would  be  in  rheumatism. 

Sometimes  scurvy  may  be  mistaken  for  poliomyelitis  or  in- 
fantile paralysis,  on  account  of  the  pseudoparalysis  of  the. legs, 
but  usually  in  infantile  paralysis  there  is  not  nearly  so  much 
tenderness,  and  the  knee-jerks  are  not  absent  in  scurvy  as  in 
infantile  paralysis.  Also,  there  is  no  swelling  of  the  legs  in  in- 
fantile paralysis. 

Occasionally,  the  severe  epiphysitis  sometimes  seen  in  cases 
of  congenital  syphilis  will  be  confused  with  scurvy,  but  usually 
there  are  other  signs  of  syphilis  present,  such  as  the  skin  lesions, 
enlarged  spleen,  etc.,  which  will  aid  in  the  diagnosis. 

I  don't  think  there  is  any  doubt  but  that  a  great  many  cases 
of  scurvy  are  overlooked.  The  tenderness  of  the  legs  is  enough 
to  suggest  a  diagnosis  in  a  great  many  cases,  even  if  there  are 
no  other  signs  or  symptoms  present. 

Treatment.— The  proper  treatment  of  scurvy  is  important 
and  it  is  a  very  satisfactory  treatment.  There  are  few  dis- 
eases that  will  respond  to  treatment  so  well  as  scurvy  does. 
It  is  remarkable  what  can  be  done  for  a  child  who  is  treated 
properly.  The  treatment  is  to  give  him  fresh  fruit-juice  or 
fresh  vegetables.  The  best  fruit  to  use  is  orange.  If  oranges 
cannot  be  obtained,  use  scraped  potato  or  scraped  apple.  Fruit- 
juices  are  better  than  vegetable  juices.  Give  the  orange-juice 
in  tablespoonful  doses  about  an  hour  before  the  feeding— four 
doses  a  day.  The  idea  of  the  treatment  is  to  supply  the  missing 
vitamins  by  giving  fruit  or  vegetable  juices,  which  contain  these 
substances.  The  peculiar  thing  is  that  the  vitamins  in  orange- 
juice  or  vegetable  juice  cannot  be  destroyed  by  cooking,  as  the 
vitamins  in  milk  can,  so  mashed  potato  is  a  fairly  satisfactory 
antiscorbutic.  Most  cases  of  scurvy  can  be  cured  in  about  a 
week  or  ten  days;  many  cases  in  three  or  four  days.  In  treat- 
ing a  child  who  has  scurvy  do  not  have  his  milk  pasteurized  or 
sterilized  if  you  can  get  good  milk.  When  a  child  is  being  fed 
on  sterilized  or  pasteurized  milk  or  on  proprietary  foods,  it  is 
better  to  give  it  small  doses  of  orange-juice  right  along,  because 
it  acts  as  a  prophylactic  and  prevents  the  development  of 
scurvy. 


RICKETS — SCURVY — SPASMOPHILIA  HI 

It  is  interesting  to  note  what  Thomas  Sydenham,  the  great 
EngHsh  physician,  writing  about  1660,  considered  his  favorite 
prescription  for  scurvy.  He  says:  "The  patient  ought  to  use 
the  following  medicated  beer  for  common  drink: 

"  Take  of  the  root  of  horseradish,  fresh  gathered,  two  drachms; 
twelve  leaves  of  scurvy  grass,  six  raisins  stoned,  and  half  a 
Seville  orange;  bruise  and  shce  the  ingredients,  and  infuse 
them  in  a  large  glass  vessel,  well  corked,  in  a  quart  of  small  beer. 

"Let  six  bottles  of  this  beer  be  made  at  one  time,  and  in  a 
few  days,  before  it  be  finished,  six  more,  and  renew  them  for  the 
future  in  the  same  manner." 


SPASMOPHILIA  (TETANY) 

Spasmophilia,  or  tetany,  is  a  condition  caused  by  a  distur- 
bance of  metabolism,  probably  connected  in  some  way  with  the 
calcium  metabolism.  It  may  occur  in  adults  or  in  cliildren  of 
any  age,  but  it.  is  most  common  in  bottle-fed  babies  from  six 
months  to  two  years  of  age.  It  is  rare  in  breast-fed  babies. 
It  is  manifested  by  extreme  nervous  irritability  with  tonic 
muscular  spasms,  especially  of  the  hands  and  feet,  with  or 
without  general  convulsions.  It  is  not  the  same  thing  as  tetanus, 
and  bears  no  relation  whatsoever  to  it.  It  is  frequently  as- 
sociated with  rickets. 

Etiology. — In  adults  tetany  may  be  caused  by  removal  of  the 
parathyroid  glands,  minute  bodies;  four  to  six  in  number,  which 
lie  near  the  thyroid  gland.  In  the  tetany  of  babies  there  may 
sometimes  be  found  small  hemorrhages  into  the  parathyroid 
glands  at  autopsy,  but  it  has  never  been  clearly  shown  just  what 
connection  the  parathyroids  have  with  it,  and  it  is  probable  that 
they  have  little  to  do  with  the  ordinary  spasmophiUa  seen  in 
small  babies. 

A  great  deal  of  experimental  work  has  been  done  with  tetany 
in  the  last  few  years,  and  various  theories  have  been  advanced 
to  explain  it.  The  most  reasonable  explanation  I  have  ever 
seen  is  one  advanced  by  Drs.  Brown  and  Fletcher,  of  Toronto, 
about  a  year  ago,  based  on  a  considerable  number  of  investi- 
gations conducted  by  them. 


112  INFANT  FEEDING    (BOSTON  METHODS) 

In  the  body,  to  preserve  the  proper  nerve  equiUbrium,  there 
must  be  present,  on  the  one  hand,  calcium  and  magnesium,  on 
the  other  hand,  sodium  and  potassium,  in  fairly  constant  ratio. 
Calcium  and  magnesium  are  nerve  sedatives ;  sodium  and  potas- 
sium are  nerve  excitants.  The  idea  is  that  spasmophilia  is  due 
to  an  abnormal  storing  up  of  sodium  and  potassium  in  the  body, 
in  excess  of  the  calcium  and  magnesium,  with  a  resulting  hy- 
perirritabihty  cf  the  nervous  system. 

This  theory  is  borne  out  by  many  chemical  data  which  I 
do  not  need  to  go  into. 

Spasmophilia  almost  always  occurs  during  the  winter  months: 
rarely,  in  the  summer.  This  theory  explains  the  seasonal  oc- 
currence by  the  fact  that  babies  are  very  Hkely  to  have  diar- 
rhea during  the  summer,  with  a  resulting  loss  of  sodium  and 
potassium,  for  it  is  well  known  that  in  the  ordinary  acid  diarrhea 
due  to  sugar  fermentation  there  may  be  a  considerable  loss  of 
these  elements.  Thus,  in  the  summer  there  is  no  chance  for  the 
storing  up  of  sodium  and  potassium,  and  so  no  spasmophilia, 
whereas  in  the  winter  months,  when  babies  are  not  so  Hkely  to 
have  loose  bowels,  there  is  more  chance  for  the  storing  up  of 
these  elements,  and  consequently  more  spasmophilia.  This  is 
borne  out  by  chnical  experience,  for  it  is  well  known  that  con- 
stipated babies  are  more  likely  to  develop  spasmophilia  than 
are  those  who  have  a  tendency  to  looseness  of  the  bowels.  So 
much  for  the  theory. 

Diagnosis. — Spasmophilia  is  not  at  all  an  uncommon  con- 
dition, and  is  easy  of  diagnosis  if  one  has  seen  previous  cases 
and  is  on  the  watch  for  it — if  one  is  not,  it  may  be  very  easily 
overlooked. 

The  chief  characteristic  of  the  condition  is  a  nervous  hyper- 
irritability.  This  is  manifested  by  peculiar  spasms  involving 
especially  the  hands  and  feet.  Another  manifestation  of  the 
condition  is  "laryngismus  stridulus."  The  spasms  of  tetany 
are  quite  characteristic:  the  hands  and  feet  are  held  in  posi- 
tions peculiar  to  the  disease. 

The  wrists  are  flexed;  the  hand  has  a  tendency  to  be  drawn 
to  the  ulnar  side;  the  fingers  are  partially  flexed  at  the  meta- 
carpophalangeal joints,  and  the  thumb  is  drawn  over  across 
the  palm  of  the  hand  toward  the  Uttle  finger.     The  feet  are 


RICKETS — SCURVY — SPASMOPHILIA  113 

extended  on  the  leg  as  far  as  possible,  and  the  toes  are  flexed  on 
the  foot.  A  description  of  these  positions  brings  little  to  the 
mind,  but  when  once  a  typical  "carpopedal"  spasm,  as  it  is 
called,  has  been  seen,  it  will  never  be  forgotten. 

In  some  of  the  cases  there  will  be  generalized  convulsions; 
in  others,  only  the  carpopedal  spasm.  The  spasms  may  occur 
a  few  times  a  day  or  be  nearly  continuous.  The  carpopedal 
spasm  is  practically  always  bilateral.  The  duration  of  a  spasm 
varies  a  good  deal :  ten  or  fifteen  minutes  is  a  fair  average.  A 
good  deal  of  pain  may  be  associated  with  the  spasm,  especially 
if  one  tries  to  unclinch  the  fingers  of  the  baby's  hand. 

An  attack  of  tetany  may  usually  be  diagnosed  by  the  char- 
acteristic position  of  the  hands  and  feet  during  a  spasm,  but 
there  are  three  other  signs  which  are  of  importance: 

Chvostek's  Sign. — This  consists  of  a  quick  contraction  of  the 
muscles  of  the  face,  especially  of  the  mouth  muscles,  when  the 
facial  nerve  is  lightly  tapped.  This  occurs  in  children  with 
spasmophilia,  but  not  in  normal  children. 

Trousseau's  Symptom. — If  the  upper  arm  of  a  baby  with 
spasmophilia  is  squeezed  so  as  to  compress  the  large  nerve- 
trunks  for  a  few  moments,  a  typical  carpopedal  spasm  results. 

The  Electrical  Reactions. — This  is  the  most  scientific  and 
accurate  way  of  diagnosing  spasmophilia,  but  is  hardly  prac- 
tical for  general  use.  The  muscles  in  babies  with  spasmophilia 
require  much  less  electricity  to  be  applied  to  them  to  cause  a 
contraction  than  do  the  muscles  of  a  normal  baby.  By  one 
familiar  with  the  method  the  exact  amount  of  electricity  neces- 
sary to  cause  the  contraction  of  a  muscle  can  be  determined; 
if  this  amount  is  less  than  the  normal,  the  baby  probably  has 
spasmophilia. 

The  characteristic  electrical  reactions  always  occur  in  cases 
of  spasmophilia — Chvostek's  and  Trousseau's  signs  may  or 
may  not.  Of  these  last  two  signs,  Chvostek's  is  l^he  more 
valuable. 

Prognosis. — Spasmophiha  untreated  may  last  indefinitely. 
Mild  spasmophilia  may  last  only  a  week  or  two.  It  is  not 
dangerous  to  life  unless  severe  general  convulsions  develop. 
Properly  treated,  it  can  usually  be  controlled  readily  in  a  few 

weeks  at  the  most. 
8 


114  INFANT   FEEDING    (BOSTON   METHODS) 

Treatment. — The  treatment  may  be  divided  into  two  parts: 
the  treatment  of  the  attack  and  the  subsequent  treatment  in 
order  to  prevent  further  attacks. 

Treatment  of  the  Attack. — The  treatment  is  the  same  as  for  an 
ordinary  convulsion.  Give  the  baby  a  large  dose  of  castor  oil 
to  get  the  bowels  cleaned  out ;  get  him  into  a  hot  tub,  and  give 
him  sodium  bromid  and  chloral  by  rectum,  or  anesthetize  with 
chloroform  if  you  prefer.  Sodium  bromid  and  chloral  can 
usually  be  given  in  large  doses  to  children  by  rectum :  5  grains 
of  chloral  and  10  of  sodium  bromid  is  not  too  much  to  give  to  a 
child  a  year  and  a  half  old.    It  is  best  given  in  a  Httle  warm  milk. 

I  never  like  to  give  morphin  to  babies  or  children  if  there  is 
any  other  drug  that  can  be  used,  for  some  of  them  bear  it  very 
poorly. 

Subsequent  Treatment. — If  the  baby  is  a  bottle-fed  baby,  as 
it  most  surely  will  be,  get  breast  milk  for  it,  if  possible.  Many 
times  the  mere  substitution  of  breast  for  bottle  milk  will  relieve 
the  condition  without  any  other  treatment.  If  breast  milk 
cannot  be  obtained,  feed  the  baby  a  milk  as  high  in  its  calcium 
content  as  possible  by  using  a  milk  to  which  precipitated  casein 
has  been  added,  as  there  is  a  good  deal  of  calcium  in  precipitated 
casein.  See  that  the  baby  has  several  free  movements  of  the 
bowels  a  day,  and  be  sure  that  it  gets  plenty  of  water  between 
feedings,  in  order  to  keep  the  kidneys  active.  I  believe  this  to 
be  of  very  great  importance — kee'p  the  kidneys  active. 

Drugs. — A  number  of  drugs  have  been  used  in  treating  spas- 
mophilia. Extract  of  parathyroid  gland  has  been  given,  with 
very  small  success,  and  it  is  probable  that  this  is  of  little  or  no 
value  in  the  treatment  of  the  infantile  type  of  tetany,  at  any 
rate. 

The  drugs  which  are  of  value  are  the  salts  of  calcium  and 
magnesium.  Calcium  lactate  may  be  given  in  large  doses — the 
dosage  depends  mostly  on  the  results  which  are  obtained  with 
it:  if  good  results  do  not  follow  its  use,  use  more.  Five  grains 
every  three  hours  is  a  safe  dose  to  start  with  for  a  baby  a  year 
old:  it  may  be  increased  if  necessary. 

Calcium  chlorid  may  be  used  in  the  same  way  and  is  said  by 
some  pediatricians  who  have  had  a  great  deal  of  experience  with 
spasmophilia  to  be  of  more  value  than  the  lactate. 


RICKETS — SCURVY — SPASMOPHILIA  115 

Run  the  dosage  of  this  up  until  it  has  some  effect  in  diminish- 
ing the  spasms  or  the  child's, stomach  is  upset.  The  great 
trouble  with  calcium  chlorid  is  that  it  is  very  irritating  to  the 
stomach. 

Subcutaneous  injections  have  been  used  by  some  pediatricians 
in  the  treatment  of  tetany,  with  considerable  success.  An  8 
percent  sterile  solution  of  magnesium  sulphate  is  used,  and  0.2 
gram  of  the  salt  is  given  for  each  kilogram  of  body  weight  of  the 
baby,  15  to  20  c.c.  being  injected  at  a  time. 

I  merely  mention  this  method  of  treatment  as  I  have  had  no 
experience  with  it  myself. 

The  use  of  calcium  salts  in  the  treatment  of  spasmophilia  is 
a  very  rational  procedure:  there  is  much  chnical  evidence  to 
support  it.  It  has  also  been  shown  experimentally  that  the 
intravenous  injection  of  calcium  will  almost  immediately  con- 
trol spasms  of  tetany  in  dogs  who  have  been  given  the  condi- 
tion by  extirpation  of  the  parathyroids.  Spasmophiha  is  a  con- 
dition which  I  am  sure  you  will  see  here  if  you  are  on  the  look- 
out for  it,  and  with  proper  treatment  good  results  can  be  ob- 
tained in  dealing  with  it. 


CLINICS 

CASE  I.— VOMITING  FROM  IRREGULAR  FEEDING 

A  breast-fed  baby  (male)  one  month  old. 

Family  History. — Two  more  healthy  children,  whom  the 
mother  nursed,  and  who  did  very  well  on  her  breast  milk.  Other- 
wise not  remarkable. 

Past  History. — Full-term  normal  deUvery;  birth  weight  un- 
known. Breast  fed  any  time  he  cries ;  no  regularity  of  any  sort 
in  the  feeding:  sometimes  the  feeding  intervals  are  half  an  hour 
apart;   sometimes  three  hours. 

Present  Complaint. — At  birth  the  baby  was  deeply  jaundiced 
(probably  icterus  neonatorum  and  of  no  significance). 

Since  birth  he  has  vomited  after  nearly  every  feeding,  usually 
immediately  after  feeding.  Sometimes  he  vomits  a  large  amount, 
but  generally  not  a  great  deal.  There  are  no  tough  curds  in 
the  vomitus,  and  it  is  rather  thick  and  creamy  in  consistence. 
Occasionally  the  vomiting  is  explosive  in  character,  but  this 
is  by  no  means  constant,  occurring  perhaps  once  a  day.  The 
baby  has  no  colic,  and  seems  well  and  healthy  except  for  the 
vomiting.  His  movements  are  inclined  to  be  constipated,  but 
are  of  fair  size :  usually  one  or  two  a  day.  He  nurses  from  ten 
to  fifteen  minutes  at  a  time,  and  his  mother  keeps  him  reason- 
ably quiet  after  the  nursing. 

Physical  Examination. — The  general  condition  of  this  baby  is 
good.  He  lies  quietly  in  his  mother's  lap,  is  bright  and  active, 
and  does  not  seem  to  have  lost  much  weight.  His  color  is  good. 
The  physical  examination  is  entirely  negative;  there  is  no  tumor 
to  be  felt  in  the  abdomen,  and  no  peristalsis  to  be  seen.  A 
stool  examination  would  be  of  value,  but  the  mother  has  brought 
no  stool. 

Discussion. — A  number  of  things  may  be  considered  in  getting 
at  the  cause  of  this  baby's  vomiting. 

1.  Pyloric  Stenosis  or  Spasm. — It  is  very  unlikely  that  he  has 
pyloric  spasm,  as  this  is  rare  in  l^reast-fed  babies  and  is  not 

116 


CLINICS  117 

likely  to  show  itself  so  soon  after  birth.  It  is  also  unlikely  that 
this  baby  has  pyloric  stenosis;  his  general  condition  is  too  good, 
and  it  is  plain  that  a  good  deal  of  food  is  getting  into  his  in- 
testine, because  he  is  in  a  state  of  reasonably  good  nutrition 
and  has  large  stools. 

The  most  probable  cause  of  his  vomiting  is  too  much  rich 
breast  milk  fed  to  him  at  irregular  intervals.  The  mother  has 
full  breasts,  with  a  good  deal  of  milk,  which  she  says  seems 
to  be  very  rich  in  quality.  The  baby  is  fed  at  any  time,  so  his 
stomach  is  often  distended,  causing  him  to  vomit.  If  the  milk 
is  high  in  fat,  as  it  seems  to  be,  this  would  also  tend  to  cause  him 
to  vomit,  and  would  also  possibly  account  partly  for  his  con- 
stipated stools. 

It  is  within  the  bounds  of  possibihty,  but  is  not  at  all  prob- 
able, that  this  mother's  milk  may  never  be  suitable  for  this 
baby,  although  it  may  be  found  upon  chemical  examination  to 
be  apparently  perfectly  normal  in  composition.  You  will 
occasionally  see  a  case  in  which  the  breast  milk  seems  to  con- 
tain some  toxic  material  that  continually  upsets  the  baby,  but 
never  assume  that  any  case  is  of  this  type  until  you  have  ruled 
out  all  other  causes  of  vomiting.  I  would  treat  this  baby  as 
follows : 

Have  him  fed  regularly  at  three-hour  intervals,  and  let  him 
nurse  only  ten  minutes  at  a  time,  and  I  believe  it  very  probable 
that  his  vomiting  will  soon  disappear  under  these  conditions  of 
feeding.  If  it  does  not  improve  after  a  thorough  trial,  it  will 
be  well  to  give  him  a  couple  of  tablespoonfuls  of  hme-water 
before  each  breast  feeding,  and  still  if  it  does  not  improve, 
substitute  a  weak  cow's  milk  modification  for  three  of  the  breast 
feedings;  if  he  vomits  the  weak  artificial  feedings,  after  thor- 
ough trial,  as  much  as  he  does  the  breast  feedings,  it  is  likely 
that  he  has  a  mild  pyloric  stenosis.  If  he  does  not  vomit  the 
cow's  milk  feedings  and  continues  to  vomit  the  breast  feedings, 
have  the  breast  milk  analyzed,  and  if  it  is  of  unfavorable  com- 
position, try  to  modify  it  by  the  methods  I  suggested  in  the 
lecture  on  breast  feeding. 

As  a  last  and  most  remote  possibility:  if  he  still  continues  to 
vomit  all  the  breast  milk  he  takes  and  to  keep  down  his  bottle 
feedings,  take  him  off  the  breast.     I  believe  the  prognosis  to  be 


118  INFANT  FEEDING    (BOSTON  METHODS) 

perfectly  good  for  this  baby,  and  that  his  vomiting  can  be  con- 
trolled simply  by  regulating  the  time  and  amount  of  his  feedings. 


CASE  n.— INDIGESTION  FROM   NERVOUS  INFLUENCES 

A  breast-fed  baby  (female)  three  weeks  old. 

Family  History. — The  second  child  of  healthy  but  very  ner- 
vous and  highly  strung  parents.  The  first  child  is  two  years  old, 
very  nervous,  and  subject  to  violent  fits  of  temper.  Otherwise 
well. 

Past  History. — Born  at  term  after  a  normal  delivery.  Birth 
weight,  8  pounds.     Breast  fed  every  two  hours. 

Present  Complaint. — The  child  has  been  very  fretful  and 
irritable  for  the  past  week,  crying  most  of  the  time,  and  appar- 
ently having  a  good  deal  of  colic,  especially  at  night.  She  does 
not  vomit,  but  has  had  a  good  deal  of  diarrhea,  having  usually 
eight  to  ten  very  loose  stools  a  day,  which  look  fairly  normal 
except  for  the  decreased  consistence.  She  seems  so  uncom- 
fortable at  night,  and  cries  so  much  that  the  family  get  very 
little  rest.  She  takes  the  breast  well,  usually  nursing  for  about 
fifteen  minutes.  She  weighs  eight  pounds  two  ounces;  prac- 
tically no  gain  since  birth. 

The  state  of  the  household  is  of  considerable  importance  in 
this  case;  it  is  in  a  good  deal  of  confusion.  The  nurse  of  the 
other  child  left  about  a  week  ago,  as  did  also  the  cook,  so  things 
have  not  been  running  very  smoothly  and  the  mother  is  worried 
and  nervous. 

Physical  Examination. — Nothing  abnormal  is  found  on  phj^si- 
cal  examination  of  the  baby,  and  she  seems  to  be  in  a  very  fair 
state  of  nutrition. 

Treatment. — The  thing  of  most  importance  to  be  done  first 
in  this  case  was  to  get  the  household  straightened  out,  especi- 
ally to  relieve  the  mother  ot  all  care  of  the  ether  child;  and 
this  was  done.  The  grandmother,  who  was  an  extremely  cap- 
able and  sensible  woman,  came  and  took  hold  of  things — took 
charge  of  the  other  child,  and  relieved  the  mother  of  all  house- 
hold responsibility.  This  is  extremely  important:  a  nursing 
mother  cannot  nurse  her  haby  satisfactorily  if  she  has  worries  on 
her  mind. 


CLINICS  119 

It  seemed  best  in  this  particular  case  to  give,  only  temporar- 
ily, however,  a  few  bottle  feedings  to  the  baby,  partly  to  rest 
the  mother  and  partly  to  rest  the  baby's  intestines,  as  it  seemed 
likely  that  the  breast  milk  was  too  rich.  The  mother  was 
directed  to  feed  the  baby  as  follows: 

6.00  a.  m.:  Breast. 

8.30  A.  M. :  Breast. 
11.00  a.m.:  Bottle. 

1.30  p.  M.:  Breast. 

4.00  p.m.:  Bottle. 

6.30  p.m.:  Breast. 

9.00  p.m.:  Bottle. 

2.00  a.m.:  Breast. 
These  three  bottle  feedings  were  arranged  in  such  a  way  that 
the  mother  had  a  chance  to  get  outdoors  in  the  morning  and 
afternoon   for  exercise  and  a  change  of  surroundings.     The 
modification  given  was  the  following: 

Fat  1  percent  Sugar  5  percent  Protein  1.2  percent 

Lime-water  3^  milk  and  cream. 

Two  ounces  were  given  at  each  feeding.  This  was  made  up 
as  follows: 

16  percent  cream ^  ounce 

Skimmed  milk 23^  oimces 

Lime-water 1  ounce 

Water 4  ounces 

Milk-sugar 1  scant  tablespoonful 

A  sample  of  the  mother's  breast  milk  was  taken  at  this  time 
and  sent  away  for  analysis.  The  baby  was  seen  one  week  later, 
and  was  found  to  be  doing  very  well.  The  irritability  and  coUc 
had  improved  a  good  deal,  and  the  stools  were  fewer  in  number 
— six  or  seven  a  day  instead  of  nine  or  ten,  as  before,  but  were 
still  diminished  in  consistence.  She  took  the  bottle  milk  well, 
and  was  not  upset  by  it.  The  report  of  the  composition  of  the 
mother's  milk  came  back  as  follows: 

Fat  3.8  percent  Sugar  6.9  percent  Protein  3  percent 

This  was  a  reasonable  composition,  except  for  the  very 
high  protein  percentage,  which  probably  had  something  to  do 


120  INFANT   FEEDING    (BOSTON   METHODS) 

with  upsetting  the  baby.  The  treatment  at  this  visit  was 
to  increase  the  length  of  the  feeding  intervals  to  three  hours, 
thus  giving  the  baby  seven  feedings  in  the  twenty-four  hours — 
four  breast  and  three  bottle.  The  fat  percentage  in  the 
bottle  milk  was  raised  to  2  and  the  sugar  percentage  to  6 
percent  and  the  mother  was  instructed  to  eat  meat  or  fish  only 
once  a  day,  in  the  hope  of  perhaps  bringing  down  the  protein 
percentage  in  her  milk. 

One  week  later  the  baby  was  found  to  be  doing  very  well; 
she  slept  nearly  all  night,  had  only  three  or  four  nearly  normal 
stools  a  day,  and  had  gained  seven  ounces.  This  time  the 
treatment  was  to  omit  two  of  the  bottle  feedings,  substituting 
breast  feedings  for  them,  thus  giving  the  baby  the  following 
feeding  schedule: 

6.00  A.  M. :  Breast. 

9.00  A.  M. :  Breast. 
12.00  M. :       Breast. 

3.00  p.m.:  Bottle. 

6.00  p.  M. .  Breast. 

9.00  p.m.:  Breast. 
Night :  Breast. 

The  baby  was  seen  twice  afterward,  and  continued  to  do  well 
under  this  regime,  gaining  from  six  to  nine  ounces  each  week. 

Discussion. — This  is  a  common  type  of  case.  Fully  as  impor- 
tant as  the  feeding,  and  perhaps  more  so,  is  it  to  get  the  house- 
hold straightened  out  and  relieve  the  mother  of  all  worry,  if 
possible.  In  this  particular  case  it  seemed  best  to  give  a  few 
bottle  feedings  temporarily,  and  it  worked  out  well,  but  in  many 
cases  this  would  not  be  advisable.  Of  course,  it  would  be  ab- 
solutely wrong  to  wean  the  baby  in  such  a  case  as  this,  nor  would 
it  be  advisable  to  take  her  entirely  off  the  breast,  even  tem- 
porarily. 

Many  babies  of  this  type  do  much  better  on  three-hour  feed- 
ing intervals  than  on  two-  or  two-and-one-half-hour  intervals, 
and  this  baby  did.  In  many  cases  no  other  treatment  will  be 
found  necessary  than  to  increase  the  length  of  the  feeding  in- 
terval. This  baby  was  left  permanently  on  one  bottle  feeding 
a  day  in  order  to  give  the  mother  a  chance  to  get  out  and  to 
get  the  baby  used  to  taking  the  bottle,  as  in  all  probability  this 


CLINICS  121 

particular  woman  will  not  be  able  to  nurse  her  baby  more  than 
six  or  seven  months.  The  strength  and  amount  of  this  bottle 
feeding  must,  of  course,  be  gradually  raised  as  the  baby  gets 
older. 


CASE  m.— A  BABY  WITH  OBSTINATE  VOMITING  CAUSED  BY 

TAKING   HIS   MILK   TOO    QUICKLY— CONDENSED   MILK 

BABIES 

H.  W.,  male,  seven  months  old,  is  brought  on  account  of 
vomiting  and  malnutrition. 

Family  History. — Unimportant.  The  second  child  of  healthy 
parents.     No  tuberculosis  in  the  family.     No  miscarriages. 

Past  History. — Full  term,  normal  delivery.  Birth  weight  not 
known;  weight  at  one  month,  73^  pounds. 

He  has  always  been  fed  on  a  bottle,  with  various  modifications 
of  condensed  milk,  up  to  two  weeks  ago,  when  the  present  feed- 
ing was  started.  He  seemed  to  digest  the  condensed  milk  well, 
but  was  always  hungry,  and  his  mother  thinks  there  has  been 
no  gain  of  weight  for  the  last  three  months.  Two  weeks  ago 
Dr.  B.  was  called  in  because  the  baby  was  not  gaining,  and  he 
put  him  on  the  following  formula: 

Skimmed  millc 24  ounces 

Lime-water 12 

Milk-sugar 2 

Barley  water 12 

Six  feedings  of  8  ounces 
Fat  0.0  to  0.5  percent        Sugar  6.25  percent        Protein  1.6  percent 
Starch,  about  0.4  percent 

Present  Complaint.— The  child  has  not  seemed  to  do  well  on 
this  feeding;  he  will  take  only  six  ounces  of  it  at  a  time,  and  he 
vomits  after  nearly  every  feeding,  so  that  his  mother  judges 
that  he  retains  only  about  half  his  food.  The  yomitus  does 
not  contain  tough  curds,  nor  do  the  stools.  He  is  ravenously 
hungry,  and  takes  his  bottle  of  six  ounces  in  about  three  min- 
utes. His  stools  are  loose  and  green,  with  small  white  curds, 
sour  smelling— about  four  to  ten  a  day.  It  should  be  said  that 
these  stools  had  been  this  way  for  about  a  month  before  he  was 
put  on  his  present  feeding,  when  he  was  taking  the  condensed 
milk  modification. 


122  INFANT   FEEDING    (BOSTON   METHODS) 

Physical  Examination. — The  striking  thing  about  him  is  that 
he  does  not  look  sick.  His  particular  characteristic  is  that  he  is 
small;  he  looks  like  a  moderately  well-nourished  baby  of  three 
or  four  months,  instead  of  one  of  seven  months.  He  is  happy 
and  active,  and  at  a  casual  glance  you  never  would  pick  out  this 
baby  as  one  who  vomits  nearly  half  what  he  eats,  and  has  a 
severe  diarrhea,  as  his  mother  says  he  has.  It  is  rather  sur- 
prising that  he  looks  in  such  good  condition,  but  as  you  feel  of 
him  you  see  that  his  good  condition  is  apparent  rather  than  real ; 
his  skin  is  loose  and  his  flesh  is  very  flabby  and  soft.  He  has 
no  teeth.  There  is  nothing  else  noteworthy  about  the  physical 
examination.     He  has  no  signs  of  rickets. 

Discussion. — This  baby  is  one  of  the  types  of  condensed  milk 
babies.  Condensed  milk  sometimes  is  of  value  to  feed  a  baby 
on  temporarily,  but  it  should  never  be  used  as  a  permanent 
diet;  if  it  is,  bad  results  are  sure  to  follow,  the  reason  for  this 
being  that  condensed  milk  is  not  a  well-balanced  food,  consist- 
ing almost  entirely  of  cane-sugar.  Speaking  very  generally, 
three  types  of  condensed  milk  babies  are  likely  to  be  seen,  as 
follows : 

1.  A  much  undernourished  baby,  thin,  and  with  rickets. 

2.  A  large,  fat  baby,  who  upon  superficial  examination  may 
appear  fairly  healthy,  but  who  is  seen  upon  closer  examination 
to  be  anemic  and  to  have  very  flabby,  soft  flesh. 

3.  A  small  baby,  underdeveloped,  of  fair  nutrition,  but  soft 
and  flabby.  It  is  to  this  last  class  that  this  particular  baby 
belongs. 

What  are  the  problems  to  consider  in  the  case  of  this  baby? 

1.  To  give  him  a  food  upon  which  he  can  gain  weight  and 
develop  normally. 

2.  To  consider  the  cause  of  his  diarrhea,  and  to  stop  it  if  we 
can. 

3.  Why  does  he  vomit,  and  what  is  the  best  way  to  stop  it? 
His  diarrhea  is  probably  due  to  the  fact  that  he  has  been  fed 

on  a  very  high  sugar  diet  (condensed  milk)  over  a  long  period  of 
time.  This  sugar  has  fermented  in  the  intestines,  with  the 
formation  of  volatile  fatty  acids,  such  as  acetic,  butyric,  etc. 
These  have  irritated  the  intestine  and  given  rise  to  an  increased 
intestinal  peristalsis  and  diarrhea.     There  is  probably  also  a 


CLINICS  123 

secondary  fermentation  of  what  little  fat  there  is  present,  and  a 
much  decreased  absorption  of  all  the  food  elements,  due  partly 
to  increased  peristalsis  and  partly  to  the  abnormally  acid  con- 
dition in  the  intestine.  The  digestion  is  weak  for  all  the  food 
elements,  especially  for  fat,  as  this  baby  has  been  fed  on  a  food 
which  contains  very  little  fat,  so  his  fat  digestion  probably  re- 
mains undeveloped.  The  indications  are  for  a  food  low  in  fat 
and  low  in  sugar,  the  sugar  used  being  dextri-maltose  instead  of 
lactose  or  sucrose,  as  it  ferments  less  readily.  He  can  also 
take  a  little  starch,  and  can  probably  be  fed  on  a  fairly  high  per- 
centage of  protein.  We  will  discuss  this  feeding  in  more  detail 
later. 

As  to  his  vomiting:  He  is  certainly  not  vomiting  from  an 
excess  of  fat,  as  he  is  on  skimmed  milk,  and  the  mother  seems 
to  be  skimming  it  carefully.  It  is  also  rather  unreasonable  to 
suppose  that  he  is  vomiting  from  protein  indigestion,  as  the 
protein  percentage  in  his  milk  is  not  high,  there  are  no  tough 
curds  in  his  vomitus  or  in  his  stools,  and  the  lime-water  in  the 
mixture  equals  50  percent  of  the  milk  and  cream,  which  would 
certainly  prevent  the  formation  of  any  tough  curds  in  the  stom- 
ach, and  vomiting  from  this  cause. 

There  are  two  things  that  may  cause  vomiting  in  a  baby, 
which  are  often  overlooked,  because  they  are  so  simple: 

1.  A  too  freely  running  nipple,  which  makes  him  fill  his  stona- 
ach  too  quickly,  and  probably  also  gulp  down  a  good  deal  of  air 
with  his  milk. 

2.  Shaking  of  the  baby  by  his  mother  after  he  has  eaten,  to 
keep  him  quiet.  A  baby's  stomach  is  placed  much  more  ver- 
tically than  an  adult's  is,  and  the  esophagus  is  relatively  shorter 
and  wider,  so  that  any  movement  when  his  stomach  is  full  is 
very  likely  to  make  him  vomit.  A  baby  should  always  be  laid 
quietly  in  his  crib  for  at  least  half  an  hour  after  he  has  eaten. 

Now  this  baby,  so  his  mother  says,  emptied  his  six-ounce 
bottle  in  three  minutes;  he  should  take  about  fifteen  minutes. 
Let  us  look  at  the  nipple.  You  see  here  is  a  nipple  with  three 
large  holes  in  it,  and  when  the  bottle  is  inverted,  the  niilk  runs 
out  in  a  steady  stream,  making  a  very  fast  nipple.  This  nipple 
is  probably  the  principal  cause  of  the  baby's  vomiting.  Let  us 
tell  the  mother  to  get  a  new  nipple  without  any  hole  m  it,  to 


124  INFANT   FEEDING    (BOSTON   METHODS) 

take  a  small  needle,  heat  it  red  hot,  and  make  a  hole  through 
the  nipple  with  it  through  which  the  milk  will  slowly  come  drop 
by  drop,  and  use  this  instead  of  the  nipples  she  has  been  using. 
Also  have  her  stop  shaking  the  baby  up  after  his  bottle;  have 
her  keep  him  absolutely  quiet  for  half  an  hour  after  each  feeding. 
As  to  the  details  of  feeding:  six  ounces  at  a  feeding  seem  to  be 
about  all  this  baby  will  stand  at  the  present  time,  so  let  us  give 
him  six  ounces  every  three  hours,  seven  feedings  a  day,  at  the 
following  times: 

6.00  A.  M. 

9.00  A.  M. 
12.00  M. 

3.00  p.  M. 

6.00  p.  M. 

9.00  p.  M. 

2.00  A.  M. 

The  formula  that  he  is  on  at  present  is  a  reasonable  formula 
for  him  except  that  we  need  to  cut  down  the  sugar  percentage 
and  substitute  a  malt-sugar  (dextri-maltose)  for  the  lactose  he  is 
now  taking.     So  let  us  give  him: 

Skimmed  milk 24  ounces 

Lime-water 12       " 

Barley  water 12       " 

Dextri-maltose 1  level  teaspoonf ul 

giving  a  percentage  of — 

Fat  0.0  to  0.5  percent        Sugar  3.05  percent        Protein  1.6  percent 
Starch  0.4  percent 

Of  course,  such  a  food  as  this  is  far  below  his  caloric  require- 
ments, and  he  will  not  gain  weight  on  it,  but  we  must  first  get 
his  vomiting  and  his  diarrhea  stra'ightened  out  before  we  can 
hope  to  make  him  gain.  He  should  probably  improve  a  good 
deal  in  a  few  days,  and  as  he  improves  his  milk  can  be  gradually 
strengthened,  but  the  fat  and  sugar  will  probably  have  to  be 
kept  fairly  low  for  some  time.  I  should  think,  in  the  course  of 
two  weeks,  that  we  might  expect  to  have  this  baby  on  some 
such  formula  as  this: 

Fat  2.5  percent    Sugar  5  percent    Protein  2.4  percent    Starch  0.75  percent 


CLINICS  125 

and  that  he  would  be  taking  seven  ounces  at  a  feeding  instead 
of  six.  Do  not  increase  the  strength  and  the  amount  of  a  for- 
mula at  the  same  time;  it  is  better  usually  first  to  increase  the 
strength  and  then  the  amount. 

What  points  may  be  brought  out  from  a  study  of  this  case? 

1.  Condensed  milk  is  an  unsuitable  food  for  a  baby  to  take 
over  any  considerable  period  of  time;  it  gets  him  into  trouble 
sooner  or  later.  Condensed  milk  is  very  likely  to  give  a  baby  a 
sugar  diarrhea  and  a  weak  digestion  for  fat. 

2.  Such  simple  things  as  big  holes  in  nipples  and  shaking  up 
after  feeding  may  cause  severe  vomiting;  it  is  not  always  neces- 
sary to  go  into  chemistry  and  science  to  explain  vomiting. 

CASE  IV.— CHRONIC   SUGAR  AND  FAT  INDIGESTION 

E.  R.,  female,  aged  five  months,  is  brought  to  the  clinic  on 
account  of  failure  to  gain. 

Family  History. — The  only  child  of  healthy  parents.  No 
tuberculosis  in  the  family.     No  miscarriages. 

Past  History. — Born  at  full  temi  after  a  normal  delivery. 
The  birth  weight  is  said  to  have  been  ten  pounds,  but  this  is 
doubtful.  Breast  fed  for  five  weeks,  when  the  breast  milk  gave 
out.  From  this  time  up  to  a  week  ago  she  had  been  fed  on 
various  combinations  of  several  different  proprietary  foods  and 
condensed  milks,  all  of  which  contained  a  very  high  percentage  of 
carbohydrate.  For  a  week  she  has  been  taking  the  following 
mixture : 

Skimmed  milk 8  ounces 

Lime-water 3 

Milk-sugar 3  rounded  tablespoons 

Water  to  make 32  ounc&s 

Four  ounces  every  three  hours. 

This  gives  a  percentage  composition  of — 

Fat  0.0  to  0.5  percent  Sugar  5.6  percent  Protein  0.8  percent 

The  chief  trouble  with  the  baby  is  failure  to  gain  weight  and 
looseness  of  the  bowels.  She  takes  her  milk  well  and  never 
vomits,  but  loses  weight  steadily,  and  has  daily  at  least  four  or 
five  rather  loose  yellowish  stools  of  about  the  consistence  of 


126  INFANT   FEEDING    (BOSTON   METHODS) 

scrambled  eggs.  These  stools  smell  strongly  acid  and  have 
many  small,  soft  white  curds  scattered  through  them. 

Physical  Examiiiation. — A  very  small,  poorly  developed  and 
nourished  baby.  The  skin  is  loose  and  dry,  showing  evidence 
of  a  considerable  loss  of  weight.  Weight,  seven  pounds.  The 
chest  is  very  small;  the  abdomen  is  prominent,  and  apparently 
out  of  all  proportion  to  the  rest  of  the  body.  There  is  slight 
general  glandular  enlargement.  The  buttocks  are  red  and  irri- 
tated. There  is  nothing  else  of  interest  about  the  physical 
examination. 

Stool  Examination. — The  stool  is  soft,  loose,  yellow  in  color, 
with  many  small  curds.  The  smell  is  strongly  acid,  as  is  the 
reaction  to  Utmus.  Microscopically  there  is  a  large  excess  of 
fat  in  the  form  of  fatty  acids  and  soap.  This  would  seem  not 
consistent  with  the  skimmed  milk  diet,  but  can  be  explained 
by  the  fact  that  the  mother  is  not  skimming  the  milk 
properly. 

Discussion  and  Treatment. — This  is  one  of  the  most  com- 
mon types  of  indigestion  seen  in  infants  under  a  year  old.  It 
is  a  combination  of  fat  and  sugar  indigestion.  The  baby  has 
been  fed  always  on  a  food  high  in  carbohydrate,  and  chronic 
sugar  indigestion  has  resulted.  The  exact  mechanism  of  the 
fat  indigestion  is  not  well  understood,  but  it  is  certain  that  in 
this  type  of  case  sugar  indigestion  does  not  represent  the  whole 
story  by  any  means,  and  that  fat  indigestion,  or  failure  of  fat 
absorption,  more  properly  speaking,  plays  fully  as  important 
a  role  as  does  the  sugar  indigestion.  Which  of  the  two  is  pri- 
mary it  is  hard  to  tell — probably  the  sugar.  The  stools  that  this 
baby  has  are  very  characteristic  of  the  condition,  and  are  so 
strongly  acid  that  they  have  excoriated  the  buttocks.  The 
treatment  is  difficult — one  of  the  most  difficult  problems  in 
infant  feeding. 

Principles  of  Treatment. — These  babies  always  do  best  on  a 
food  low  in  fat  and  sugar  and  high  in  protein  in  an  easily  as- 
similable form.  In  most  cases,  but  not  in  all,  a  malt-sugar 
preparation  is  tolerated  better  than  milk-sugar.  The  principle 
of  feeding  is  the  same  as  for  fermentative  diarrhea:  to  change 
the  reaction  of  the  intestine  from  strongly  acid  to  faintly  acid, 
neutral,  or  faintly  alkaUne  by  feeding  to  the  baby  a  high  protein 


CLINICS  127 

and  a  low  fat  and  sugar  food,  the  end-products  of  which  will  be 
alkaline. 

If  we  feed  a  baby  of  this  type  from  a  milk  laboratory,  the 
problem  is  comparatively  simple:  we  write  a  prescription  for 
so  much  fat,  sugar,  and  protein  in  the  milk,  and  it  is  delivered 
at  the  door  next  morning  all  made  up.  In  feeding  cases  of  this 
type  from  a  milk  laboratory  I  nearly  always  use  a  mixture  con- 
taining a  low  percentage  of  fat  and  malt-sugar  and  a  high  per- 
centage of  protein  in  the  form  of  precipitated  casein.  Some- 
times I  use  olive  oil  in  place  of  the  milk-fat;  in  these  cases  the 
whole  mixture  is  run  through  the  homogenizing  machine,  thus 
making  a  very  easily  digested  preparation,  as  the  protein  is  in 
the  form  of  precipitated  casein  and  cannot  coagulate  in  the 
stomach,  and  the  fat-globules  have  been  broken  up  so  finely  by 
the  homogenization  that  their  digestion  and  absorption  are  very 
easy.  If  a  milk  laboratory  is  not  available,  the  next  best  food 
upon  which  to  feed  these  cases  is  Finkelstein's  "Eiweiss"  milk. 
Very  good  results  are  often  obtained  with  this. 

Details  of  Treatment. — Finkelstein's  "Eiweiss"  milk,  you 
remember,  is  made  up  as  follows:  Heat  one  quart  of  whole 
milk  to  100°  F.  Add  four  tablespoons  of  essence  of  pepsin  and 
stir.  Let  it  stand  at  100°  F.  until  a  curd  has  formed,  and  strain 
off  the  whey  from  the  curd.  Press  the  curd  through  a  fine  sieve 
three  or  four  times.  Add  one  pint  of  water  to  the  curd  and  one 
pint  of  buttermilk  to  this  mixture.  This  gives  a  food  contain- 
ing— 

Fat  2.5  percent  Sugar  1.5  percent  Protein  3  percent 

So  let  us  put  this  baby  on  "Eiweiss"  milk,  giving  eight  feed- 
ings of  four  ounces  each  to  start  with.  Later  the  amount  can 
be  increased.  It  will  be  better,  also,  at  first  to  have  the  mother 
make  the  curds  from  skimmed  milk  instead  of  whole  milk, 
as  this  baby's  fat  tolerance  is  low,  and  she  will  probably  do 
better  on  a  food  containing  very  little  fat.  Later  we  can  raise 
the  fat  percentage.  She  will  probably  need  to  be  kept  on 
"Eiweiss"  milk  for  several  weeks.  After  several  days,  if  her 
movements  become  better  and  tend  more  to  the  alkaUne  re- 
action, malt-sugar  may  be  added  to  3  or  4  percent.  After  four 
or  five  weeks  the  "Eiweiss"  milk  may  be  gradually  discon- 


128  INFANT   FEEDING    (BOSTON   METHODS) 

tinued  and  she  can  be  put  on  a  skimmed-milk  and  gravity  cream 
modification,  with  a  rather  low  fat  and  sugar  and  a  higher  pro- 
tein percentage. 

You  will  say  that  such  a  method  of  milk  preparation  is  too 
complicated  for  many  people  to  carry  out.  This  is  true;  it  is  a 
rather  complicated  method,  but  with  such  a  baby  as  this  it  is 
impossible  to  obtain  satisfactory  results  with  simple  milk  and 
water  dilutions.  Neglected  babies  of  this  type  have  practically 
no  chance  of  surviving;  properly  treated,  most  of  them  do  very 
well. 

CASE  v.— THE  FEEDING  OF  AN  EIGHTEEN-MONTHS-OLD  BABY 
WITH  CHRONIC  FERMENTATIVE  DIARRHEA 

W.  L.,  male,  eighteen  months,  is  brought  on  account  of  diar- 
rhea. 

Family  History. — Not  remarkable.  The  only  child  of  healthy 
parents.     No  tuberculosis  in  the  family.     No  miscarriages. 

Past  History. — Full-term,  normal  delivery.  Birth  weight 
unknown.  He  was  breast  fed  ten  months  and  then  was  put  on 
whole  milk,  cereals,  bread,  and  potato.  He  has  always  been 
well,  although  not  particularly  rugged,  until  the  onset  of  his 
present  complaint  four  weeks  ago. 

Present  Complaint. — For  nearly  four  weeks  he  has  had  diar- 
rhea— from  seven  to  ten  loose  green  stools,  containing  mucus, 
a  day.  These  stools  have  contained  a  good  many  small  white 
curds,  but  there  has  been  at  no  time  any  blood  present.  He 
has  had  a  little  fever  at  night  occasionally, — from  100.5°  to 
101.5°  F., — but  has  had  a  good  appetite,  not  seeming  particu- 
larly sick.  He  has  never  been  weighed,  but  his  mother  thinks  he 
has  lost  a  good  deal  during  the  last  four  weeks.  At  present  he  is 
taking  skimmed  milk  and  barley  water,  equal  parts,  eight  ounces, 
six  times  a  day.  In  the  last  few  days  his  stools  have  been  a 
little  better,  but  he  still  passes  five  or  six  a  day ;  they  are  very 
loose,  slightly  green,  and  contain  many  fine  white  curds. 

Physical  Examination. — As  we  look  at  this  baby  we  can  see 
that  his  general  appearance  indicates  that  he  has  lost  a  good  deal 
of  weight,  but  still  that  he  is  not  yet  in  the  "atrophic"  stage. 
He  is  pale,  with  dark  circles  beneath  his  eyes;  his  flesh  is  very 
flabby  and  his  skin  loose.     He  has  probably  lost  from  four  to 


CLINICS  129 

five  pounds  in  the  last  few  weeks.  His  abdomen  is  prominent 
and  lax;  his  liver  is  felt  about  4  cm.  below  the  costal  margin. 
There  is  nothing  else  of  interest  about  the  physical  examina- 
tion.    He  has  no  evidences  of  rickets. 

Discussion. — This  child  has  probably  had  a  fermentative 
diarrhea,  due  to  carbohydrate  fermentation,  from  which  he  is 
slowly  recovering.  The  fact  that  he  at  no  time  had  blood  in  his 
stools,  that  he  did  not  seem  particularly  sick,  and  that  he  had 
very  little  temperature,  would  rule  out  infectious  diarrhea. 
We  know  that  his  diarrhea  is  due  to  fermentation  of  carbohy- 
drate because  the  stools  are  acid  in  reaction  and  gfeen  in  color. 
He  has  never  been  fed  a  particularly  high  carbohydrate  food, 
so  we  can  assume  that  his  trouble  came  in  the  beginning  from 
milk  probably  infected  with  the  Bacillus  proteus,  the  colon 
bacillus,  or  one  of  the  numerous  other  microorganisms  that  may 
cause  fermentative  diarrhea.  He  has  been  treated  reasonably 
and  well,  and  has  improved  somewhat,  but  not  nearly  so  fast 
as  he  should  have  done.  What  is  the  reason  for  this?  Let  us 
inquire  into  the  particulars  of  the  milk  he  is  taking  and  its  mode 
of  preparation. 

We  find  that  the  milk  he  is  taking  comes  from  a  Jersey  cow 
owned  by  his  father;  that  it  is  skimmed  after  standing  only  two 
hours,  and  that  it  is  not  boiled. 

When  we  examine  his  stool  microscopically  we  find  that  it 
consists  almost  entirely  of  soap,  although  it  is  supposed  that  he 
is  being  fed  on  a  milk  free  from  fat.  This  means  that  the  milk 
is  not  being  properly  skimmed,  and  as  it  is  a  rich  milk  from  a 
Jersey  cow,  this  child  is  probably  getting  at  least  2  percent  of 
fat  in  his  diet,  when  he  should  have  none.  It  is  of  great  im- 
portance to  keep  the  fat  low  in  this  case,  and  this  is  why  he 
has  not  improved  more  rapidly.  This  is  a  very  important 
point — you  may  think  you  are  feeding  a  skimmed  milk  some- 
times, but  are  not  at  all,  because  the  milk  may  be  very  rich 
milk  to  start  with,  and  is  not  being  skimmed  properly.  You 
will  see  a  great  many  cases  like  this.  Let  us  tell  this  mother 
not  to  skim  the  milk  until  it  has  stood  six  hours,  and  then  to 
get  all  the  cream  off  that  she  can.  Of  course,  it  is  impossible 
to  obtain  an  absolutely  fat-free  milk  by  hand  skimming,  but  it  is 
probable  that  the  fat  can  be  reduced  to  0.5  percent  or  less. 
9 


130  INFANT  FEEDING    (BOSTON  METHODS) 

Also,  we  will  tell  her  to  boil  the  milk  five  minutes;  this  is  im- 
portant. The  weather  is  very  hot  at  present,  and  milk  spoils 
quickly  in  this  climate  if  it  is  not  boiled,  and  it  is  probable  that 
contaminated  milk  was  the  cause  of  this  child's  trouble  to  begin 
with,  so  let  us  boil  his  milk  ten  minutes.  If  you  feed  a  child 
for  any  length  of  time  on  boiled  milk,  it  is  best  to  give  him 
orange-juice,  to  prevent  the  development  of  scurvy,  but  we 
shall  not  start  giving  orange-juice  to  this  particular  baby  until 
his  diarrhea  has  cleared  up.     Let  us  give  him  this  modification: 

Skimmed  milk 24  ounces 

Barley  water 24       " 

Six  feedings  of  eight  ounces  each. 

This  mixture  has  the  following  composition: 

Fat  0.0  percent  Sugar  2.25  percent  Protein  1.6  percent 

Starch  0.75  percent 

This,  of  course,  is  a  very  weak  milk  for  this  baby,  but  we  must 
feed  him  on  a  weak  milk  for  a  few  days,  as  he  is  at  present  un- 
able to  digest  a  stronger  one.  We  shall  see  him  again  next  week. 
Weight  at  present,  20  pounds.  He  probably  will  do  well,  but 
will  gain  weight  slowly. 

July  5th. — He  is  taking  his  milk  well  and  is  having  two  or 
three  small  stools  a  day — slightly  acid,  yellowish,  no  excess  of 
fat  microscopically.  Weight,  193^  pounds.  It  is  safe  to  raise 
his  feeding  a  little,  so  we  can  give  him  now  48  ounces  of  un- 
diluted skimmed  milk,  with  the  addition  of  four  tablespoonfuls 
of  dextri-maltose,  giving  a  sugar  percentage  of  7.7,  which  is  a 
fairly  high  sugar  percentage  to  feed  to  a  baby  such  as  this; 
but  he  is  in  such  good  condition  that  he  will  probably  stand  it. 
If,  after  a  day  or  two  of  this  feeding,  he  has  no  trouble,  we  will 
tell  his  mother  to  give  him  four  tablespoons  of  barley  jelly  a  day. 
It  is  best  to  have  his  milk  skimmed  for  a  while  longer.  We 
give  dextri-maltose  because  it  is  usually  much  more  easily 
handled  by  babies  of  this  sort  than  lactose  is,  and  is  not  so  easily 
fermented.  You  remember  I  told  you  in  a  previous  lecture 
how  to  make  barley  jelly;  four  tablespoons  of  barley  flour  to  a 
pint  of  water;  cook  one  hour  in  a  double  boiler,  add  enough 
water  to  make  up  to  a  pint  again,  strain  and  salt.  This  is  an 
extremely  valuable  preparation  to  feed  babies  on  (over  a  year 


CLINICS  131 

old)  who  are  convalescing  from  diarrhea,  either  infectious  or 
fermentative,  and  I  want  to  urge  you  to  use  it  a  great  deal  more 
than  you  do:  it  is  not  used  half  enough.  In  fermentative  diar- 
rhea the  digestion  for  fat  is  poor,  as  is  that  for  sugar,  but  the 
digestion  for  starch  in  moderate  amounts  is  usually  good,  be- 
cause it  is  broken  down  so  slowly  in  the  intestine  that  its  end- 
products  are  present  in  small  amounts  and  have  little  chance 
to  ferment.  Powdered  zwieback  is  also  valuable  to  use  in 
such  conditions. 

July  12th. — Weight,  193^^  pounds.  He  is  not  doing  well; 
he  is  very  hungry,  and  has  had  a  bad  diarrhea  for  the  last  few 
days.  When  we  examine  the  stools  we  see  that  they  are  of  a 
greenish-brown  color,  slightly  acid,  without  curds,  and  of  a.  very 
mucilaginous  consistence,  with  many  small,  jelly-like  masses. 
When  we  examine  them  microscopically  with  Sudan  III  and 
acetic  acid,  we  see  that  there  is  no  excess  of  fat  present,  but 
when  we  add  iodin,  we  see  many  small  blue  starch-granules. 
The  appearance  of  this  stool  is  absolutely  characteristic  of 
acute  starch  indigestion,  so  that  is  what  is  troubling  this  baby  at 
present;  he  is  either  getting  too  much  starch  in  his  diet  or  is 
not  digesting  what  he  does  get,  at  any  rate.  We  had  this  baby 
on  four  tablespoonfuls  of  barley  jelly  a  day,  which  certainly 
ought  not  to  be  too  much  for  him,  so  let  us  ask  the  mother  just 
how  she  makes  the  barley  jelly  and  how  much  he  takes  of  it. 
We  find  she  makes  it  exactly  according  to  the  directions  we  gave 
her  last  week,  but  that  she  thought  I  said  four  tablespoonfuls 
with  each  feeding,  instead  of  only  four  during  the  day,  so  the  baby 
is  getting  24  tablespoonfuls  of  barley  jelly  a  day.  No  wonder 
he  has  starch  indigestion.  This  illustrates  the  importance  of 
writing  down  all  orders  for  feeding  cases.  I  should  have  done 
it  for  this  one.     Let  us  feed  him  as  follows: 

Skimmed  milk 48  ounces  (six  feedings 

of  8  ounces) 
Dextri-maltose 3  tablespoons 

for  two  days,  and  then  if  he  does  well,  change  the  feeding  to  this: 

Whole  milk 4  ounces 

Skimmed  milk 44       " 

Dextri-maltose 3  tablespoons 

Barley  jelly 3  tablespoons  a  day 


132  INFANT  FEEDING   (BOSTON  METHODS) 

This  gives  a  percentage  of: 

Fat  0.33  percent        Sugar  6.9  percent        Protein  3.2  percent 

July  1.9th. — He  is  doing  very  well,  is  hungry  and  gaining 
weight.  Two  stools  a  day — no  excess  of  fat.  Weight,  20 
pounds.     Let  us  increase  his  feeding  to: 

Whole  milk 16  ounces 

Skimmed  milk 32      "        (six  feedings  of 

eight  ounces) 

Dextri-maltose 2  tablespoons 

Barley  jelly 3  tablespoons  a  day 

Zwieback 2  a  day 

Orange-juice 2  tablespoons  a  day 

July  26th. — Doing  well,  but  has  not  gained.  Stools  one  or 
two  a  day — normal  looking.  He  has  not  gained,  because  he  is 
still  on  a  diet  far  below  his  caloric  requirements,  and  he  has 
grown  tired  of  barley  jelly  and  has  refused  it  at  nearly  every 
feeding.  It  is  safe-  to  increase  his  diet  a  good  deal  this  time,  so 
let  us  give  him: 

Whola  milk 24  oimces 

Skimmed  milk 24       " 

Dextri-maltose 2  tablespoons  (giving  a  per- 
centage of  fat,  2;  sugar, 
6.1;    protein,  3.2) 

Farina 6  tablespoons  a  day 

Zwieback 4  a  day 

Orange-juice 2  tablespoons  a  day 

Farina  or  Cream  of  Wheat  is  a  most  excellent  food  for  small 
babies,  and  is  probably  the  best  cereal  to  give  them  after  they 
have  graduated  from  barley  jelly.  It  is  important  to  cook  it 
very  thoroughly;  it  should  be  cooked  at  least  half  %  day  in  a 
double  boiler.  It  is  better  to  give  it  without  sugar  if  the  child 
will  take  it  this  way. 

August  2d. — Weight,  213^  pounds — a  gain  of  13^2  pounds  in 
the  last  week.  The  child  looks  very  much  better  and  is  going 
ahead  fast. 

How  shall  we  feed  him  now?  We  can  consider  him  now  as 
essentially  a  normal  baby,  and  we  can  feed  him  as  such,  except 
that  we  must  still  keep  -he  fat  in  his  diet  rather  low,  or  it  is  very 
doubtful  whether  he  would  take  full  Jersey  milk  even  now. 


CLINICS  133 

He  needs  more  solid  food.  A  baby  of  this  age,  on  a  normal 
diet,  should  not  take  over  a  quart  of  milk  a  day,  for  if  he  does 
he  will  not  take  enough  solid  food.  So  let  us  cut  his  daily  milk 
allowance  to  32  ounces  and  have  it  mixed  as  follows: 

Whole  milk 16  ounces 

Skimmed  milk 16      "       (four   feedings  of   eight 

ounces  each) 
Dextri-maltose 1  tablespoon 

Fat  2  percent     Sugar  5.3  percent     Protein  3.2  percent 

For  the  rest  of  his  diet,  give  him  the  regular  infant  diet  list, 
which  I  detailed  to  you  in  a  previous  lecture.  He  should  have 
five  meals  a  day,  about  as  follows: 

6  or  7  A.  M. :    8  ounces  milk 
8.30  A.  M. :    Cereal  and  8  ounces  milk 
Zwieback  and  apple-sauce 
11.30  A.  M.:    8  ounces  milk 
Zwieback 
1.30  p.  M.:    Soup  or  beef-juice 

Mashed  potato  or  macaroni 
Mashed  peas 
Egg 
Custard 
5.30  p.  M.:    8  ounces  milk 
Cereal 
Zwieback 
Stewed  prunes  or  apple-sauce 

What  are  the  lessons  to  be  drawn  from  a  study  of  this  case? 

1.  Treat  fermentative  diarrhea  due  to  carbohydrate  with  a 
food  relatively  low  in  sugar  and  fat  and  high  in  protein. 

2.  Be  sure  that  the  fat  in  the  diet  is  actually  low;  that  the 
mother  is  skimming  the  milk  in  the  right  way,  and  is  doing  it 
completely.  Take  into  consideration  whether  or  not  the  family 
has  a  Jersey  cow.  Many  babies  who  are  supposed  to  be  on  a 
practically  fat-free  milk  may  have  stools  full  of  fat  and  do 
poorly,  simply  because  the  milk  is  not  being  skimmed  properly. 

3.  Write  down  carefully  all  directions  to  the  mother:  do  not 
trust  to  verbal  directions. 

4.  Raise  the  diet  slowhj,  first  adding  a  malt-sugar  preparation 
and  then  starch  (to  babies  over  a  year  old) .  Then  small  amounts 
of  fat.  Write  out  the  exact  quantities  of  each  article  of  diet 
the  baby  is  to  have. 


134  INFANT  FEEDING    (BOSTON  METHODS) 


CASE  VI.— FERMENTATIVE  DIARRHEA  IN  A  SMALL  BABY| 

J.  C,  male,  five  weeks  old,  is  brought  on  account  of  diarrhea. 

Family  History. — Four  other  children  well.  No  miscarriages. 
No  tuberculosis  in  the  family. 

Past  History. — Born  at  full  term  after  a  normal  delivery. 
Birth  weight,  83^2  pounds.  Breast  fed  five  days,  when  the 
mother  had  abscesses  in  both  breasts,  which  made  artificial 
feeding  necessary.  He  was  put  on  3^  milk  and  3^  water,  with 
milk-sugar  added  to  about  6  percent,  234  ounces  every  two  and 
one-half  hours.  He  did  very  well  on  this  formula  until  yester- 
day, when  he  began  to  have  diarrhea.  Yesterday  he  had  seven 
movements;  today  he  has  already  had  six  up  to  3  p.  m.  The 
stools  are  loose  and  green,  but  contain  no  blood  or  pus.  They 
smell  strongly  acid  and  are  also  strongly  acid  in  reaction. 

Physical  Examination. — A  fairly  well-nourished  baby,  mod- 
erately sick  at  the  present  time,  with  a  temperature  of  101°  F. 
The  physical  examination  is  entirely  negative:  there  is  no 
cause  for  the  diarrhea  to  be  found  outside  of  the  digestive  tract. 

Discussion  and  Treatment. — This  is  a  typical  case  of  fermen- 
tative diarrhea  of  the  carbohydrate  type.  The  onset,  the 
general  condition  of  the  baby,  and  the  loose,  green,  acid  stools 
are  quite  characteristic.  The  condition,  as  I  have  said  before, 
is  due  to  an  abnormal  fermentation  of  sugar  in  the  intestine. 
This  sugar  is  broken  down  into  various  acids,  such  as  acetic 
and  butyric,  which  irritate  the  intestinal  mucous  membrane 
and  cause  a  diarrhea.  The  condition  may  be  brought  about 
sometimes  by  too  great  an  amount  of  sugar  in  the  food,  which  is 
broken  down  by  the  bacteria  normally  present  in  the  intestinal 
tract,  or  it  may  be  caused  by  the  introduction  of  harmful  bac- 
teria from  without,  in  unclean  milk.  In  this  particular  case 
the  condition  is  probably  due  to  the  latter  cause,  as  this  baby  has 
been  fed  throughout  on  a  reasonable  sugar  percentage.  The 
general  plan  in  treating  these  babies  is  first  to  empty  the  in- 
testinal tract,  if  the  baby  has  not  already  had  enough  move- 
ments to  do  this,  and  then  to  give  a  food  low  in  sugar  and  fat 
and  high  in  protein.  The  decomposition  products  of  protein 
are  alkaline  in  reaction,  and  if  such  a  food  as  this,  with  a  low 
fat  and  sugar  content  and  a  high  protein,  is  given,  the  reaction 


CLINICS  135 

of  the  intestinal  contents  will  return  to  normal.  If  there  is 
little  sugar  there,  it  cannot  be  fermented,  and  so  no  more  acid 
can  be  formed. 

It  will  be  best  to  purge  this  baby  well,  so  let  us  give  it  two 
teaspoonfuls  of  castor  oil,  repeated  in  three  hours.  (If  the 
diarrhea  had  existed  for  several  days  and  the  baby  were  having 
12  or  15  stools  a  day  instead  of  the  6  or  7  he  is  having,  we  would 
give  no  cathartic.)  Then  give  sterile  water,  2^^  ounces  every 
two  and  one-half  hours  for  twenty-four  hours,  after  which  milk 
feeding  may  be  started.  Let  us  put  this  baby  on  the  following 
formula: 

Skimmed  milk 12  oimces 

Lime-water 6      " 

Water 6       " 

2]/2  ounces  every  two  and  one-half  hours;  boil  the  mix- 
ture five  minutes. 

This  gives  a  percentage  composition  of 
Fat  0.0  percent  Sugar  2.5  percent  Protein  1.6  percent 

The  milk  is  boiled  partly  to  sterilize  it  and  partly  to  make  the 
curd  from  the  protein  softer  and  smaller.  As  the  movements 
improve,  in  the  course  of  a  day  or  two  I  would  begin  to  substi- 
tute small  amounts  of  whole  milk  for  a  portion  of  the  skimmed 
milk,  and  would  also  add  sugar  up  to  4  percent,  in  the  form  of 
dextri-maltose. 

As  the  baby  improves  the  modification  can  be  gradually 
strengthened,  until,  in  the  course  of  seven  or  eight  days,  if 
everything  goes  well,  he  should  be  taking: 

Fat  2  percent       Sugar  5  percent       Protein  1.6  percent 
23^  ounces  every  two  and  one-half  hours. 

I  should  give  no  drugs  of  any  sort  other  than  castor  oil  to  this 
baby.  This  is  given  because  this  particular  baby  needs  a  purge; 
its  intestine  has  not  been  thoroughly  emptied.  Colonic  irri- 
gations would  probably  do  this  baby  no  good. 

Eiweiss  milk  could  be  used  in  the  treatment  of  this  case,  and 
it  is  likely  that  the  bowels  would  clear  up  more  quickly  with  the 
Eiweiss  milk  than  they  would  on  the  mixture  we  prescribed,  as 
there  is  less  sugar  and  more  protein  in  Eiweiss  milk  than  there 


136  INFANT   FEEDING    (BOSTON   METHODS) 

is  in  our  mixture.  This  baby,  however,  has  not  a  very  severe 
diarrhea,  and  will  probably  do  well  on  the  simple  dilution  we 
have  prescribed,  so  there  is  no  need  of  giving  a  complicated 
formula,  especially  as  this  mother  is  in  very  moderate  circum- 
stances, has  four  other  children,  and  has  a  house  to  take  care  of, 
with  no  spare  time  on  her  hands  to  take  up  in  mixing  Eiweiss 
milk. 

CASE  Vn.— INFECTIOUS  DIARRHEA 

R.  G.,  male,  nineteen  months,  is  brought  to  the  clinic  on 
account  of  diarrhea. 

Family  History. — Three  more  children  well:  none  dead.  No 
miscarriages.     No  tuberculosis  in  the  family. 

Past  History. — Full-term,  normal  delivery.  Birth  weight 
unknown.  Breast  fed  for  fifteen  months,  then  put  on  undiluted 
cow's  milk,  rice,  eggs,  cereal,  and  bread.  He  has  never  been 
sick,  and  has  done  very  well  in  every  way  up  to  the  onset  of  his 
present  complaint. 

Present  Illness. — ^A  week  ago  he  began  to  have  diarrhea,  at 
first  four  or  five  then  eight  or  nine  loose  brownish-green  stools  a 
day,  containing  a  good  deal  of  mucus.  There  was  no  blood  in 
the  stools  at  first,  but  for  the  past  few  days  they  have  contained 
blood  in  streaks,  intimately  mixed  with  the  mucus  and  fecal 
material.  The  number  of  the  stools  is  increasing:  yesterday 
he  had  12,  with  a  good  deal  of  straining  and  tenesmus.  Three 
days  ago  he  had  a  temperature  of  103°  F. ;  since  then  it  has  been 
between  99.5°  and  100.5°  F.  He  has  been  considerably  pros- 
trated since  the  onset  of  his  illness,  is  listless  and  apathetic,  and 
has  a  very  poor  appetite.     No  nervous  sjTnptoms  or  vomiting. 

For  five  days  he  has  been  fed  on  albumin  water,  about  six 
ounces  every  three  hours,  with  ten  drops  of  brandy  added  to 
each  feeding. 

Physical  Examination. — His  general  condition  is  only  fair; 
he  lies  relaxed  and  limp,  and  takes  very  little  interest  in  any- 
thing. His  eyes  are  sunken,  his  skin  is  loose  and  dry,  and  his 
abdomen  is  considerably  sunken.  He  seems  to  have  lost  a 
good  deal  of  weight. 

There  is  nothing  else  of  interest  about  the  physical  examina- 
tion. 


CLINICS  137 

Treatment. — There  is  no  use  in  giving  a  purge  to  this  baby; 
the  time  to  purge  him  was  at  the  onset  of  his  illness,  when  he 
was  having  only  a  few  stools  a  day  and  was  in  good  general  con- 
dition ;  but  at  present  he  is  having  so  many  stools,  and  so  much 
straining  with  them,  that  it  would  undoubtedly  do  him  more 
harm  than  good  to  purge  him  now. 

There  seems  to  be  no  reason  for  starving  him  either;  he  has 
been  practically  starved  for  a  week,  and  let  me  say  here  a  word 
or  two  about  starvation  in  this  condition.  It  is  not  good  prac- 
tice to  starve  a  baby  too  long;  rarely  should  any  baby  with 
infectious  diarrhea  be  starved  over  twenty-four  to  forty-eight 
hours.  I  know  that  we  all  used  to  starve  our  cases  of  infectious 
diarrhea,  sometimes  for  long  periods,  but  experience  has  shown 
that  this  is  not  the  best  method  of  treatment,  and  that  these 
babies  will  do  much  better  if  they  are  fed  a  weak  milk  mixture 
almost  from  the  very  first,  after  a  short  period  of  starvation. 
I  have  seen  a  great  many  cases  of  infectious  diarrhea  fed  on 
albumin  water,  and  do  not  believe  in  it — for  two  reasons:  First, 
because  there  is  practically  no  nourishment  in  albumin  water, 
and  we  do  not  wish  to  starve  the  baby;  secondly,  because  al- 
bumin water  consists  entirely  of  protein  (and  water),  and  the 
dysentery  bacillus,  which  is  the  cause  of  most  cases  of  infectious 
diarrhea,  attacks  protein  very  readily,  and  forms  toxic  decom- 
position products  from  it.  So  the  indications  are,  in  treating 
most  cases  of  infectious  diarrhea,  to  feed  a  food  high  in  carbo- 
hydrate and  low  in  protein,  as  the  dysentery  bacillus  does  not 
readily  thrive  on  carbohydrate  food,  and  the  decomposition 
products  which  it  produces  from  carbohydrate  are  not  particu- 
larly toxic. 

To  return  to  our  baby.  A  reasonable  feeding  on  which  to 
start  this  baby  would  be  the  following: 

Skimmed  milk 14  ounces 

Barley  water  (1.5  percent) 14 

Lime-water 7 

Boiled  water 7 

Lactose 6  level  tablespoons 

Seven  feedings  of  six  ounces  each. 

This  gives  the  following  percentages: 

Fat  0.0  percent    Sugar  7  percent    Protein  1  percent    Starch  0.5  percent 


138  INFANT   FEEDING    (BOSTON   METHODS) 

As  you  can  see,  this  is  a  food  low  in  fat  and  protein  and  high 
in  sugar.  It  is  always  important  to  keep  the  fat  low  in  feeding 
these  babies  with  infectious  diarrhea,  as  it  is  usually  impossible 
for  them  to  digest  even  small  quantities  of  fat.  This  formula 
could  soon  be  raised  to  the  following: 

Skimmed  milk 21  ounces 

Barley  water 14      " 

Lime-water 7      " 

Lactose 6  level  tablespoons 

The  principles  in  the  further  dietetic  treatment  of  this  baby 
are  these: 

1.  Gradually  raise  the  strength  of  his  food  until,  as  he  is  be- 
ginning to  convalesce  and  is  having  fewer  stools,  he  will  be  tak- 
ing undiluted  skimmed  milk  with  sugar  added  to  6  or  7  percent. 
Also,  at  this  time,  he  can  be  given  a  little  more  starch  in  the 
form  of  barley  jelly,  farina,  or  powdered  zwieback. 

2.  The  last  thing  to  do  is  to  raise  the  fat,  and  this  should  be 
done  slowly,  by  substituting  every  few  days  an  ounce  or  two  of 
whole  milk  for  an  equivalent  amount  of  skimmed  milk. 

3.  As  he  convalesces  gradually  add  other  articles  of  food  to 
his  diet,  remembering  that  no  baby  of  this  age  can  thrive  on 
milk  alone.  This  baby's  digestion  for  starch  will  probably  be 
good,  so  that  barley  jelly,  farina,  powdered  zwieback,  mashed 
potato,  macaroni,  etc.,  are  the  articles  of  solid  food  that  you  will 
rely  on  mostly  for  his  subsequent  diet.  As  he  progresses  he  can 
be  given  beef -juice  and  a  small  amount  of  finely  chopped  meat. 
If  he  shows  any  tendency  to  sugar  fermentation,  it  will  be  best 
to  substitute  maltose  for  lactose. 

At  the  present  time  I  would  give  this  baby  no  drugs,  except 
possibly  a  few  small  doses  of  paregoric  to  diminish  the  tenesmus, 
which  has  apparently  troubled  him  a  good  deal  in  the  last  day 
or  two. 

It  is  important  to  give  him  water  between  his  feedings,  and 
this  I  would  do.  Also,  as  this  baby  has  lost  a  good  deal  of  fluid 
and  at  the  present  time  is  pretty  well  dried  out,  I  would  give 
him  about  200  c.c.  of  normal  salt  solution  subcutaneously.  I 
feel  that  this  is  very  important  in  treating  these  babies,  and  it 
will  often  give  surprisingly  good  results.     I  believe  that  in  a  good 


CLINICS  139 

many  fatal  cases  of  infectious  diarrhea  the  loss  of  fluid  from  the 
body  is  one  of  the  most  important  factors  in  causing  death.  It 
is  best  not  to  give  the  fluid  under  the  breasts,  as  is  usually  done, 
but  to  give  it  in  the  loose  tissue  of  the  abdomen  on  either  side 
of  the  umbilicus.  A  baby  with  infectious  diarrhea  has  none  too 
much  strength;  it  is  important  to  conserve  as  much  of  it  as 
possible,  and  if  a  pint  of  water  is  suddenly  placed  on  his  chest 
and  he  has  to  raise  it  (sometimes  a  tenth  or  a  fifteenth'  of  his 
own  weight)  every  time  he  breathes,  it  may  tire  him  a  good  deal. 
At  present  I  should  give  no  colonic  irrigations  to  this  baby, 
but  later  on,  if  his  stools  do  not  clear  up  as  well  as  they  should, 
and  they  continue  to  show  a  good  deal  of  pus  and  mucus,  I 
would  give  him  every  day  a  high  colonic  irrigation  with  3  percent 
silver  nitrate  solution. 

CASE  Vm.— ACUTE  RICKETS 

J.  S.,  male,  was  seen  March,  1917.    Age,  nine  months. 

Complaint. — Poor  appetite;  failure  to  gain. 

Family  History. — Not  remarkable. 

Past  History.— Full  term;  difficult  high  forceps  delivery. 
Birth  weight,  seven  pounds.     Never  breast  fed. 

Feeding.— He  has  always  been  fed  on  "top-milk"  mixtures, 
and  these  have  contained  a  high  percentage  of  fat— usually 
over  4  percent.  For  the  last  month  he  has  been  on  the  follow- 
ing feeding : 

Top  (14  ounces  of  two  quarts) 25  ounces 

Skimmed  milk 13 

Dextri-maltose 6  level  tablespoons 

Five  feedings  at  four-hour  intervals;  from  63^  to  7  ounces  at 
a  feeding.  With  this  he  also  gets  about  six  teaspoonfuls  of 
beef -juice  a  day. 

Present  Illness.— He  gained  weight  very  satisfactorily  up  to 
four  weeks  ago.  The  mother  has  been  plotting  the  weight 
curve  in  Dr.  Holt's  little  book,  and  it  has  followed  the  theo- 
retical curve  very  closely  up  to  this  time.  For  four  weeks  his 
weight  has  remained  stationary,  however.  His  appetite  is 
poor:  sometimes  he  takes  only  three  or  four  ounces  at  a  feed- 
ing.    He  never  vomits.     He  has  one  or  two  very  large,  pasty, 


140  INFANT  FEEDING    (BOSTON  METHODS) 

light-colored  stools  a  day.  For  the  last  few  weeks  he  has  been 
very  fussy,  sleeps  poorly,  cries  a  good  deal,  and  sweats  pro- 
fusely, especially  about  the  head.  At  no  time  has  he  had  any 
apparent  fever.     Weight,  17%  pounds. 

Physical  Examination. — Looking  at  this  baby  casually,  with 
his  clothes  on,  one  would  be  inclined  to  consider  him  a  fairly 
healthy  baby,  except  for  a  certain  pallor,  and  this  is  what  his 
parents  have  considered  him :  an  unusually  strong  and  healthy 
baby.  He  is  bright  and  active,  and  interested  in  his  surround- 
mgs. 

When  his  clothes  are  removed,  however,  it  is  easy  to  see  that 
he  is  in  poor  condition.  The  essential  points  of  the  physical 
examination  are  these: 

General  Condition. — Flabby  and  soft;  his  skin  hangs  loosely 
upon  his  flesh. 

Skin  and  mucous  membranes:    Pale. 

Head:  Normal  in  shape;  anterior  fontanel  and  sutures 
widely  open.     No  craniotabes. 

Throat:  Large  tonsils  and  a  discharging  nose,  which  means 
infected  adenoids.     He  has  no  teeth. 

Lymph-nodes:  Generally  enlarged,  especially  those  of  the 
neck,  some  of  which  are  as  large  as  marbles. 

Chest:  Small  in  comparison  with  the  abdomen.  A  well- 
marked  "rosary"  is  present,  but  no  Harrison's  grooves. 

Lungs:  Normal. 

Heart:  Normal. 

Abdomen:  Large  and  flabby,  with  very  thin,  lax  walls.  Dias- 
tasis of  recti  muscles.  The  liver  edge  is  felt  about  3  cm.,  and 
the  spleen  easily  2  cm.,  below  the  costal  margin. 

Extremities:  Negative;  no  enlargement  of  the  epiphyses; 
no  tenderness;  no  spasm  or  paralysis.     Knee-jerks  normal. 

Discussion. — Of  course,  this  baby  has  acute  rickets.  The 
anemia,  fiabbiness,  delayed  dentition,  enlarged  spleen,  rosary, 
etc.,  make  this  diagnosis  unmistakable. 

The  question  is,  how  did  he  get  it  and  what  can  be  done  for 
him? 

As  I  said  in  the  lectures,  rickets  is  a  complex  condition,  and 
may  be  due  to  a  number  of  causes,  either  singly  or  combined. 
Poor  hygienic  surroundings  have  nothing  to  do  with  this  baby's 


CLINICS  141 

condition,  as  his  parents  are  very  well  to  do  and  he  has  always 
had  the  best  of  everything.  The  cause  of  his  trouble  is  to  be 
looked  for  in  his  feeding :  he  has  always  been  fed  on  a  food  very 
high  in  fat.  The  formula  that  he  is  taking  now  contains  a 
httle  over  5  percent,  which  is  altogether  too  much  for  him. 
This  excess  of  fat  has,  however,  not  been  enough  to  upset  his 
digestion  much,  to  make  him  vomit  or  to  give  him  a  diarrhea. 
The  way  in  which  it  has  done  him  harm  is  this :  the  fat  of  cow's 
milk  is  not  easily  absorbed,  partly  owing  to  the  fact  that  the 
free  volatile  fatty  acids  of  the  fat  combine  with  the  calcium 
salts  of  the  milk  and  form  insoluble  calcium  soaps,  which  can- 
not be  absorbed.  Thus,  on  account  of  the  large  amount  of  fat 
in  this  baby's  food,  the  calcium  of  the  food,  which  should  be 
absorbed,  has  been  rendered  unavailable,  and  on  account  of 
this  long-continued  loss  of  calcium  he  has  developed  rickets. 
Not  all  cases  of  rickets  are  caused  in  this  way,  but  a  great  many 
are,  at  any  rate. 

According  to  my  way  of  thinking,  the  feeding  of  this  baby  has 
been  entirely  wrong  from  the  start.  I  very  rarely  believe  in 
four-hour  feeding  intervals  for  most  babies  under  a  year  old.  If 
they  are  fed  in  this  way,  it  is  necessary  to  feed  them  too  con- 
centrated a  food,  and  I  have  happened  to  see  lately  a  number  of 
babies  who  have  come  to  grief  fed  by  this  method. 

There  was  no  opportunity  to  analyze  the  stool  of  this  baby, 
but  I  am  sure  that  if  an  analysis  had  been  possible,  at  least  40 
percent  of  the  fat  intake  would  have  been  found  in  the  stool,  a 
large  part  of  it  in  the  form  of  calcium  soap. 

TTeatment— Feeding.— The  feeding  of  this  baby  was  changed 
to  the  following  Walker-Gordon  formula: 

Fat 3.00  percent 

Sugar  (d6xtri-maltose) 8.00        '' 

Protein 2.40        ;; 

Barley  starch 0./5 

Sodium  citrate  1  grain  to  the  ounce  of  milk  and  cream. 

Seven  to  eight  ounces  every  three  hours;  six  feedmgs 
in  twenty-four  hours.  ,      •     j  • 

(About  the  same  percentages  could  be  obtamed  in  a 
home  modification  by  using  36  ounces  of  whole  milk, 
12  ounces  of  3  percent  barley  water,  dextri-maltose,  b 
level  tablespoons,  sodium  citrate,  half  a  teaspoonful.) 


142  INFANT  FEEDING    (BOSTON  METHODS) 

The  baby  has  not  been  seen  since  he  was  put  on  this  formula, 
but  I  feel  sure  that  he  will  do  better  on  it  than  he  did  on  the 
other. 

Ordinarily,  beef -juice  would  not  be  given  to  a  baby  as  young 
as  this,  but  it  has  probably  done  him  no  harm,  and  it  may  as 
well  be  continued.  Personally,  I  think  that  beef-juice  is  greatly 
overrated,  and  while  I  do  use  it,  do  not  consider  it  at  all  a  neces- 
sary part  of  a  baby's  diet. 

Drugs. — Iron  is  definitely  indicated  for  the  anemia,  and  sac- 
charated  oxid  of  iron,  3  grains  three  times  a  day,  was  prescribed. 

The  following  prescription  was  also  given: 

Phosphorated  oil 20  minims 

Cod-liver  oil 4  ounces 

One  teaspoonful  once  a  day;  after  a  few  days,  twice  a  day. 

It  is  very  doubtful  whether  cod-liver  oil  and  phosphorus  do 
much  good  in  rickets,  but  they  are  worthy  of  a  trial.  Cod-liver 
oil  in  small  amounts  is  assimilated  more  easily  than  cow's  fat, 
so  even  if  the  baby  has  been  taking  too  much  fat,  there  is  no 
contraindication  for  the  small  extra  amount  of  fat  that  he  will 
get  in  the  oil. 

Fresh  air  and  sunlight  are  of  the  utmost  importance  for  this 
baby.  He  should  be  out-of-doors  or  on  an  open  porch  nearly 
all  day  on  reasonably  good  days.  It  must  be  remembered, 
however,  that  he  is  anemic,  and  that  for  this  reason  he  will  not 
stand  cold  well,  and  should  not  be  sent  out  on  very  cold  days. 

Prognosis. — It  will  be  possible  to  make  him  gain  weight,  to 
help  his  anemia  and  generalcondition,  and,  I  hope,  to  arrest  or 
to  modify  the  rachitic  process.  Just  how  much  this  process 
can  be  arrested  or  modified,  however,  is  a  question,  but  it  does 
not  seem  likely  that  this  case  will  be  a  severe  one,  and  it  is  prob- 
able that  the  baby  will  recover  without  atiy  serious  deformities. 

CASE  IX.— MIXED  BREAST  AND  BOTTLE  FEEDING 

R.  W.,  male,  is  first  seen  February  10,  1917.  Age,  eight 
weeks. 

Complaint. — Failure  to  gain. 

Family  History. — The  only  child  of  healthy  parents.  No 
miscarriages,  no  exposure  to  tuberculosis. 


CLINICS  143 

Past  History. — Born  at  full  term,  normal  delivery.  Birth 
weight,  1%  pounds.     Breast  fed  every  two  and  one-half  hours. 

Present  Illness. — The  baby  is  brought  on  account  of  failure 
to  gain  weight;  he  has  remained  stationary  at  eight  pounds  for 
several  weeks.  It  takes  him  half  an  hour  to  empty  the  breast, 
and  then  he  is  not  satisfied.  No  vomiting.  Movements  one  a 
day,  small,  rather  hard,  and  constipated.  The  mother  says  she 
thinks  she  has  very  little  breast  milk.  She  is  a  young,  highly 
intelligent,  normal  appearing  woman,  is  on  a  reasonable  diet, 
and  is  drinking  about  two  quarts  of  fluid  a  day. 

Physical  Examination. — A  rather  small,  poorly  nourished 
baby,  who  has  apparently  started  on  the  road  downhill.  His 
flesh  is  flabby,  and  his  skin  is  loose  and  pouchy,  although  he  is 
not  in  an  extremely  emaciated  condition.  Weight,  eight  pounds 
(weight  of  a  normal  baby  of  eight  weeks  should  be  about  ten 
pounds).  The  rest  of  the  physical  examination  is  essentially 
negative. 

Discussion. — ^Although  this  case  is  by  no  means  a  difficult  or 
a  complicated  one,  I  have  included  it  because  it  represents  a 
very  important  group.  There  are  a  great  many  women  who 
can  partially  nurse  their  babies,  but  who  have  to  be  helped 
somewhat  with  the  bottle.  This  woman  is  of  this  type:  her 
milk  is  agreeing  with  the  baby  perfectly,  although  there  is  not 
quite  enough  of  it.  The  point  I  want  to  emphasize  particularly 
is  this :  never  wean  a  baby  simply  because  the  mother  has  too  little 
milk  or  because  it  is  too  weak.  Even  if  she  can  give  the  baby  only 
four  or  five  ounces  a  day,  let  him  have  it.  It  may  seem  quite 
unnecessary  to  lay  so  much  emphasis  upon  this,  but  I  have 
seen  dozens  of  babies  taken  off  the  breast  entirely  and  put  on 
various  proprietary  foods  simply  because  the  mother  did  not 
have  enough  milk  for  them.  The  thing  to  do  in  such  cases  is 
to  help  out  the  breast  milk  by  supplementary  feedings  of  the 
bottle.  The  bottle  milk  is  usually  given  immediately  after 
each  nursing,  although  if  the  mother  has  only  a  very  little  breast 
milk,  it  will  probably  be  necessary  to  have  several  feedings  at 
which  the  bottle  is  given  alone.  There  are  relatively  few 
women  who  can  nurse  their  babies  successfully  for  a  whole  year, 
and  mixed  feeding  often  has  to'be  resorted  to,  usually  with  very 
good  results. 


144  INFANT   FEEDING    (BOSTON  METHODS) 

Treatment. — In  this  particular  case  the  treatment  was  as 

follows:   The  mother  was  instructed  to  nurse  the  baby  fifteen 

minutes  every  two  and  one-half  hours — eight  feedings  in  the 

twenty-four  hours,  and  immediately  after  each  nursing  to  give 

two  ounces  of  a  Walker-Gordon  modification  containing  the 

following: 

Lactose  5  percent 

Fat  2  percent  Protein  1.4  percent 

Maltose  1  percent 
Sodium  citrate,  1  grain  to  each  ounce  of  milk  and 
cream  in  the  mixture. 

The  maltose  was  added  to  correct  the  constipation,  which  it 
did  very  effectually. 

If  this  particular  formula  had  been  prepared  at  home,  it 
would  have  been  made  as  follows: 

Gravity  cream 2  ounces 

Skimmed  milk 5       " 

Water 9       " 

Milk-sugar 1}4  level  tablespoons 

Maltine  malt  soup 1  scant  level  tablespoon 

Sodium  citrate 7  grains 

The  baby  did  very  well  on  this  feeding,  and  started  to  gain 
immediately.  On  February  17th  his  weight  was  8  pounds  10 
ounces,  a  gain  of  10  ounces  in  one  week,  and  his  progress  there- 
after was  very  satisfactory. 


CLINICAL  LECTURES 

ON 

INFANT  FEEDING 

Chicago  Methods 

BY 

JESSE  ROBERT  GERSTLEY,  M.D. 


TO 

DRS.  I.  A.  ABT.  JULIUS  H.  HESS,  ERNEST  LACKNER,  AND 
JOSEPH  BRENNEMANN 

THE  MEN  WHO  FIRST  STIMULATED  ME  TO  DREAM  OF  A 
EUROPEAN   EDUCATION,  AND  TO 

MY  PARENTS 

WHO  MADE  THIS  DREAM  A  REALITY 


PREFACE 

The  following  lectures  are  the  result  of  many  influences. 
Two  years  spent  in  the  European  clinics  with  Finkelstein  and 
his  able  assistants,  L.  F.  Meyer  and  Ivan  Rosenstern,  with 
Czerny  and  with  Knoepfelmacher,  gave  the  writer  the  founda- 
tion. It  was  upon  the  recommendation  of  Dr.  JuHus  H.  Hess, 
Professor  of  Pediatrics  at  the  University  of  Ilhnois,  that  the 
writer  went  to  North  Carohna.  The  welcome  cooperation  of 
the  State  University  and  the  State  Board  of  Health  was  in- 
valuable in  its  effect.  To  the  energy  and  interest  of  Dr.  J.  W. 
Long,  organizer  of  the  western  sections,  and  chairman  of  the 
splendid  organization  of  men  in  Greensboro,  the  writer  is  par- 
ticularly indebted.  He  was  a  constant  encouragement  and  a 
large  factor  in  the  success  of  the  work.  The  warm  hospitality 
and  great  personal  kindness  of  Drs.  Henry  Long,  of  Statesville, 
Mitchell  Summerell,  of  China  Grove,  F.  Raymond  Taylor,  of 
High  Point,  R.  E,  Flippen,  of  Pilot  Mountain,  I.  W.  Faison,  of 
Charlotte,  and  many  other  good  friends  in  North  Carolina, 
changed  an  exceedingly  hard  summer  into  a  pleasant  vacation. 
Before  commencing  his  own  course  the  writer  had  the  pleasure 
of  hearing  several  clinics  of  his  friend.  Dr.  Lewis  Webb  Hill. 
This  privilege  aided  the  writer  greatly  in  outlining  his  own  work. 
Many  subjects  which  Dr.  Hill  covered  thoroughly,  the  writer 
omitted  in  order  to  avoid  unnecessary  repetition. 

Those  of  the  readers  who  are  familiar  with  Finkelstein,  may 
find  in  the  following  pages  some  variations  from  his  writings. 
These  are  due  to  unpublished  views  obtained  in  personal  con- 
versation, and  to  others  which  the  writer  has  introduced  upon 
his  own  responsibihty  and  from  his  own  experience. 

In  classifying  the  following  pages  as  Chicago  methods  of 
feeding,  the  writer  by  no  means  wishes  to  imply  that  these  are 
the  methods  of  all  Chicago  pediatricians.  However,  he  be- 
lieves himself  justified  in  stating  that  the  majority  of  Chicago 

149 


150  PREFACE 

men  have  been  influenced  to  a  decided  extent  by  the  schools  of 
Finkelstein  and  Czerny. 

The  chnics  following  the  lectures  are  made  up  of  the  case 
records  of  the  course.  In  his  notes  the  writer  at  times  neglected 
to  record  the  names  of  the  physicians  bringing  the  patient  or 
raising  questions  for  discussion.  He  has  attempted  to  fill  these 
in  from  memory,  and  so  may  have  made  errors.  He  trusts  that 
this  liberty,  taken  in  the  interest  of  teaching,  will  be  overlooked. 
The  curves  are  elaborations  of  the  crude  blackboard  sketches; 
the  photographs  are  from  our  hospital  wards,  taken  to  help 
illustrate  the  discussions. 

The  writer  is  indebted  to  Dr.  Alexander  Day,  of  Northwestern 
University  Medical  School,  for  his  kind  suggestions  as  to  the 
charts,  to  Mrs.  Edna  Walsh  for  much  help  in  the  manuscript, 
and  to  the  pubUshers  for  their  many  courtesies. 

Jesse  Robert  Gerstley 
Chicago,  III., 
September,  1917. 


CLINICAL  LECTURES  ON  INFANT  FEEDING 
(CHICAGO  METHODS) 


LECTURE  I 
INTRODUCTION 

Gentlemen:  In  coming  to  discuss  with  you  the  subject  of 
children's  diseases,  I  have  been  confronted  with  a  serious  prob- 
lem. To  cover  thoroughly  the  entire  field  of  pediatrics  in  thir- 
teen lectures  is  obviously  impossible.  To  skim  over  it  super- 
ficially would  leave  you  only  with  false  impressions,  would  be 
worse  than  useless,  and  would  do  more  harm  than  good.  In 
attempting  to  plan  the  course,  I  thought  it  might  be  wiser  to 
devote  most  of  our  time  to  those  subjects  in  which  ignorance  or 
lack  of  experience  of  the  physician  leads  to  greatest  injury  to  the 
patient.  Probably  in  no  other  field  of  medicine  are  graver  mis- 
takes made  than  in  that  of  infant  feeding  and  nutrition.  Lasting 
misfortunes  are  brought  upon  infants  from  sheer  ignorance  of  some 
of  the  simplest  rules  of  feeding  and  hygiene.  Indeed,  one  almost 
might  say  that  if  we  have  mastered  infant  feeding,  in  addition 
to  a  little  hygiene,  there  would  be  no  sick  babies.  Don't  take 
this  statement  too  literally.  But  I  make  it  boldly,  and  repeat 
it,  to  show  how  much  emphasis  I  lay  upon  the  subject.  For 
this  reason  I  intend  devoting  the  major  part  of  the  course  to 
these  considerations. 

In  the  clinics  following  the  lectures  we  probably  shall  see  and 
discuss  some  of  the  more  familiar  conditions. 

In  the  lectures  upon  infant  feeding  and  nutrition  we  shall  fol- 
low rather  closely  the  teachings  and  viewpoints  developed  by  the 
Finkelstein  clinic  and  its  converts.  I  also  shall  take  the  liberty 
of  including  in  these  discussions  points  advanced  by  other  clinics; 
may  at  times  venture  to  criticize  some  of  these  views  on  the 

^  151 


152  INFANT   FEEDING    (CHICAGO   METHODS) 

basis  of  my  personal  experience,  and  occasionally  shall  insert 
ideas  of  my  own.  Don't  misunderstand  me;  we  of  the  Middle 
West  have  absolutely  no  objection  to  the  percentage  system  of 
feeding.  It  undoubtedly  gives  good  results  in  the  hands  of 
men  used  to  it ;  but  we  believe  our  methods  simpler  to  use  and 
simpler  to  teach  than  those  more  commonly  employed  in  the 
United  States. 


MILK 

When  we  seek  a  substitute  for  breast  milk,  there  is  one,  and 
only  one,  to  offer,  and  that  is  cow's  milk.  No  greater  injustice 
can  be  done  to  a  child  than  by  failure  of  the  physician  to  recog- 
nize or  know  this  ti'uth.  No  matter  what  advertisements  you 
read;  no  matter  what  claims  are  made  for  proprietary  foods, 
absolutely  no  substitute  has  been  found  for  cow's  milk.  In 
view  of  its  importance,  let  us  devote  ourselves  this  morning  to 
a  rather  careful  study  of  it,  considering  its  chemistry,  bac- 
teriology, and  physical  qualities. 

After  you  realize  the  importance  of  cow's  milk  as  a  food 
all  the  more  striking  must  be  the  statement  of  M.  J.  Rosenau, 
the  eminent  professor  of  preventive  medicine  at  Harvard,  from 
whose  writings  on  milk  I  now  rather  extensively  quote,  that 
milk  is  responsible  for  more  sickness  and  more  deaths  than  all 
other  foods  combined.  Gentlemen,  just  think  what  this  state- 
ment means:  The  one  food  next  to  breast  milk  in  quality  is 
responsible  for  more  deaths,  not  than  any  other  food  but  than 
all  other  foods  combined!  And  it  is  this  food  we  must  feed 
our  babies. 

According  to  Rosenau,  the  reasons  for  this  statement  are 
four: 

1  Milk  is  an  ideal  culture-medium  for  bacteria.  They  grow 
very  well  in  it. 

2.  It  is  the  most  difficult  of  all  foods  to  handle  and  to  deliver. 

3.  It  is  the  most  decomposable  of  all  foods. 

4.  It  is  the  only  standard  article  of  diet  obtained  from  animal 
sources  used  raw.  When  one  stops  to  think  how  we  cook  meat, 
eggs,  boil  soups,  and  cook  all  animal  foods,  it  is  surprising  that 
we  still  use  milk  in  raw  form. 


MILK  153 

COMPOSITION   OF  MELK 

Milk  is  composed  of  five  elements  of  food — ^not  three,  as  we 
were  wont  to  consider,  but  five.  These  five  are:  protein,  fat, 
carbohydrate,  salts,  and  v)ater.  It  is  the  salts  and  water  that 
are  so  frequently  overlooked  in  the  feeding  of  children  and  in 
the  treatment  of  nutritional  disturbances,  and  which  are  of  such 
importance.     We  shall  hear  more  of  them. 

Protein  is  the  substance  which,  in  connection  with  salts,  gives 
structure  to  the  tissues.  Protein  is  composed,  in  a  general  way, 
of  carbon,  oxygen,  hydrogen,  and  nitrogen.  When  we  speak 
of  nitrogen-containing  foods,  we  mean  protein  in  distinction  to 
the  fats  and  carbohydrates,  which  contain  only  carbon,  oxygen, 
and  hydrogen.  Protein  in  the  milk  is  not,  as  you  may  think,  a 
specific  element,  but  exists  as  two  kinds,  viz.,  casein;  and  al- 
bumins and  globulins. 

Casein  is  the  substance  that  forms  thick  curds  when  milk  is 
coagulated.  The  curds  in  buttermilk  are  of  casein,  and  it  is 
this  casein  that  is  the  most  important  form  of  protein  as  regards 
infant  feeding. 

Albumins  and  globulins  form  a  scum  on  top  of  the  milk  when 
it  is  boiled.  We  always  have  thought  them  unimportant  as 
regards  feeding. 

Fat  exists  in  the  milk  as  an  emulsion  of  fat-droplets.  As  a 
food,  it  is  of  value  in  supplying  some  energy  to  the  body,  and 
also  is  stored  up  in  the  tissues.  It  is  the  most  variable  constitu- 
ent of  the  milk.  The  first  milk  of  the  nursing  or  of  the  milking 
is  poorest  in  fat.  The  last  is  richest.  Fat  varies  in  the  milk  of 
different  animals.  Jerseys  and  Guernseys  contain  more  than 
Holsteins,  and,  not  infrequently,  a  baby  who  is  vomiting  can  be 
cured  by  changing  from  the  milk  of  a  Guernsey  to  a  Holstein. 

Carbohydrate  in  milk,  commonly  known  as  sugar  of  milk,  and 
technically  called  lactose,  is  of  value  in  supplying  energy  to  the 
body.  Like  casein,  lactose  is  found  only  in  the  mammary  glands 
and  nowhere  else  in  nature.  When  bacteria  attack  it,  it  usually 
is  changed  to  lactic  acid,  this  being  the  acid  that  is  formed  m 
buttermilk;  so  buttermilk  is  simply  milk  in  which  the  fat  has 
been  removed  and  the  sugar  changed  to  lactic  acid. 

Salts  in  connection  with  casein  furnish  structure  to  the  tissues, 


154  INFANT   FEEDING    (CHICAGO   METHODS) 

and  are  vitally  concerned  in  many  of  the  nutritional  disturb- 
ances. 

Water  is  perhaps  the  most  important  element  in  the  body, 
being  the  universal  solvent  and  constituting  the  greatest  pro- 
portion of  the  body  tissues. 

Besides  these  substances,  a  great  variety  of  drugs  and  also 
some  ferments  may  be  found.  From  the  standpoint  of  medicine 
these  drugs  are  unimportant,  because  they  rarely  are  of  suffi- 
cient quantity  to  have  any  effect  upon  the  child.  An  exception 
may  be  made,  however,  in  the  case  of  cows  that  have  eaten 
poisonous  weeds  and  grasses. 


ADULTERATION   OF  MILK 

If  you,  gentlemen,  are  interested  in  the  study  of  children's 
diseases,  you  must  know  the  ways  in  which  milk  is  adulterated. 
The  most  common  methods  are  skimming,  watering,  adding 
thickening  agents  and  preservatives.  To  detect  these  adul- 
terations three  means  are  at  our  disposal: 

1.  Simple  inspection. 

2.  Bacteriological  tests. 

3.  Chemical  tests. 

The  method  that  I  would  recommend  to  you,  one  which  is 
simple  enough  for  any  one,  is  that  of  inspection.  Take  the  milk 
and  look  at  it.  Here,  of  course,  you  detect  gross  changes.  Then 
filter  through  a  piece  of  cotton  placed  in  a  little  funnel.  Heat- 
ing the  milk  makes  it  filter  more  easily.  On  this  cotton  you  will 
find  a  stain  varying  from  light  brown  to  black,  depending  upon 
the  amount  of  dirt.  Looking  at  the  cotton,  one  finds  all  sorts 
of  things;  Cow's  hairs,  manure  and  feces,  scales  of  her  skin, 
sand,  straw,  and  food.  It  is  well  to  remember  that  a  wise  milk- 
dealer  sometimes  filters  the  milk  before  selling  it. 

The  only  chemical  test  that  I  would  recommend  is  the  Bab- 
cock.  This  requires  a  special  apparatus,  but  those  who  are  in- 
terested may  at  some  time  wish  to  have  one.  It  is  a  quantitative 
test  for  fat.     This  is  the  technic : 

Take  17.5  c.c.  of  milk 

17.5  c.c.  of  sulphuric  acid 
2.0  c.c.  of  amyl  alcohol 


MILK  155 

I  give  you  these  in  the  metric  system,  for  the  tubes  are  gradu- 
ated that  way.  Remember  that  30  c.c.  equal  1  ounce;  so  we 
are  using  approximately  one-half  ounce  each  of  these  fluids. 
Centrifuge  for  four  minutes;  then  add  boiling  water  to  bring 
the  fat  up  into  the  graduated  neck  of  the  tube;  centrifuge  for 
two  minutes  and  read. 

Other  chemical  and  bacteriological  methods  require  special 
training. 


DIFFERENCES  BETWEEN  COW'S  MILK  AND  BREAST  MILK 

A  proper  understanding  of  the  difference  in  the  composition 
of  cow's  milk  and  breast  milk  is  absolutely  essential  to  the  feed- 
ing of  infants  and  is  the  basis  of  all  our  methods  of  treatment. 
Let  us  give  you  this  little  table,  which,  though  not  absolutely 
accurate,  still  is  sufficient  for  all  practical  purposes: 

Breast  Milk  Cow's  Milk 

Protein 2.0  percent  Protein 4.0  percent 

Fat 4.0      "  Fat 4.0      " 

Carbohydrate....  6.0      "  Carbohydrate....  4.0      " 

Salts 0.2      "  Salts 0.7      " 

Water 88.0      "  Water 87.0      " 

An  easy  way  of  carrying  these  numbers  in  your  head  is  this: 
breast  milk  being  2  4  6;  cow's  milk  4  4  4.  Looking  at  this 
table,  one  gets  the  impression  that  the  only  difference  between 
the  two  milks  is  in  the  amount  of  the  different  constituents. 
This,  however,  is  not  the  case. 

Protein,  as  you  remember,  exists  in  the  milk  as  two  different 
elements:  casein,  and  albumin  and  globulin.  The  proportion 
of  these  elements  in  the  milk  is  entirely  different. 

Protein  of  cow's  milk  contains: 

Casein 85+  percent 

Albumins  and  globulins. 14+ 


The  protein  in  the  breast  milk  consists  of: 

Casein ?J±  P®*"?!®"* 

Albumins  and  globulins 38  + 

To  emphasize  this  all  the  more,  look  at  the  weights.    If  we 


156  INFANT  FEEDING    (CHICAGO  METHODS) 

take  100  grams  (a  little  over  3  ounces)  of  milk  and  weigh  these 
different  proteins,  we  find: 

Coin's  Milk 

Casein 2.7  grams 

Albumins  and  globulins 0.2  gram 

Breast  Milk 

Casein 0.8  gram 

Albumins  and  globulins 0.6      " 

Notice  the  preponderance  of  casein  in  cow's  milk;  and  now, 
in  addition  to  this,  there  is  also  a  difference  in  the  caseins  of  the 
mixtures  themselves.  Cow's-milk  casein  precipitates  in  firm, 
thick  curds;  breast-milk  casein  forms  only  the  finest  curds — 
sometimes  none  at  all;  and  cow's-milk  casein  contains  much 
more  phosphorus  than  breast-milk  casein.  I  emphasize  these 
differences  to  show  how  futile  it  is  to  attempt  to  modify  cow's 
milk  so  as  to  make  its  protein  identical  to  that  of  breast  milk. 

So  far  as  we  know  at  present,  the  composition  of  breast  milk 
cannot  definitely  be  influenced  by  diet  other  than  that  a  poorly 
nourished  woman,  who  secretes  little  milk,  may  perhaps  be 
made  to  produce  larger  quantities  by  building  up  her  nutrition. 

Fat. — Like  the  proteins  of  the  two  mixtures,  the  fats  are  of 
somewhat  different  chemical  composition.  The  fat  of  cow's 
milk  contains  more  of  the  irritating  lower  fatty  acids,  of  which 
butyric  acid  is  an  example,  and  there  may  even  be  some  bio- 
logical variations. 

Carbohydrates,  so  far  as  we  know,  are  alike. 

Salts. — Like  the  protein  and  the  fats,  there  is  great  difference 
in  the  salt  content  of  the  two  mixtures,  not  only  in  quantity,  but 
in  quality.  Those  in  cow's  milk  are  chiefly  calcium  and  mag- 
nesium; those  in  breast  milk,  chiefly  sodium  and  potassium. 
So  you  see  we  cannot,  in  any  simple  way,  modify  cow's  milk  so 
as  to  make  its  salt  content  identical  to  that  of  breast  milk. 

BACTERIAL  GROWTH  IN  MILK 

In  offering  an  infant  cow's  milk,  we  frequently  overlook  the 
rapid  growth  of  bacteria  that  may  have  taken  place  if  the  milk 
has  not  properly  been  cared  for.     Even  if  it  has  been  kept  at  a 


MILK  157 

relatively  low  temperature,  within  two  days  bacteria  will 
have  multiplied  by  the  millions,  and  at  warmer  temperatures 
the  numbers  found  are  absolutely  incredible.  Rosenau'a 
statement  certainly  is  impressive  when  he  says  that  the  milk 
we  drink  or  we  offer  to  an  infant  may  contain  more  bacteria 
than  are  found  in  ordinary  sewage.  Just  think  of  this! 
In  feeding  your  babies  milk  mixtures  you  may  be  feeding  more 
bacteria  than  are  in  ordinary  sewage!  These  bacteria  are 
usually  of  the  type  attacking  the  sugar  and  forming  lactic  acid, 
thus  making  sour  milk,  but  they  may  be  of  any  sort,  and  as 
they  grow  they  may  produce  two  important  types  of  change: 

(1)  If  they  attack  carbohydrate  they  produce  acid,  this  proc- 
ess being  known  as  fermentation.  In  this  fermentation  usually 
lactic  acid  is  produced,  but  under  certain  conditions  other  acids 
also  result. 

(2)  If,  on  the  other  hand,  they  attack  the  protein,  they  pro- 
duce alkahne  products,  this  process  being  known  as  putrefaction. 

Gentlemen,  I  urge  you  to  distinguish  sharply  between  these 
two  processes  and  remember  that  we  shall  hear  of  them  time  and 
time  again.  You  cannot  feed  a  normal  baby,  nor  can  you  treat 
a  baby  sick  with  nutritional  disturbance  unless  you  have  this 
clear-cut  understanding  of  the  changes  that  bacteria  produce  in 
milk.  Let  me  repeat:  When  bacteria  attack  carbohydrate,  the  proc~ 
ess  is  known  as  fermentation,  and  acids  result.  When  bacteria 
attack  protein,  the  process  is  called  putrefaction,  and  alkalis  resuU. 

From  our  standpoint  of  feeding,  however,  we  must  remember 
that  the  numbers  of  bacteria  that  are  present  in  milk  are  by  no 
means  as  important  as  the  kind,  and  this  brings  us  to  the  dis- 
cussion of  the  diseases  which  are  known  definitely  to  be  carried 
by  milk. 

MILK-BORNE  DISEASES 

Studies  have  shown  that  tuberculosis,  typhoid,  diphtheria, 
scarlet  fever,  dysentery,  and  many  other  diseases  have  been 
traced  to  the  milk  supply.  A  study  made  in  Boston  some  time 
ago  shows  what  a  factor  milk  can  be  in  spreading  disease,  par- 
ticularly among  children.     To  quote  Rosen au: 

In  1907,  in  Boston,  72  cases  of  diphtheria  and  717  cases  of 
scariet  fever  were  transmitted  by  milk.     In  1908,  400  cases  of 


158  INFANT  FEEDING    (CHICAGO  METHODS) 

typhoid  were  due  to  this  cause.  In  1910,  over  842  cases  of 
scarlet  fever  had  this  same  origin;  and  in  1911,  over  2065  cases 
of  septic  sore  throat  again  were  due  to  this  cause.  Gentlemen, 
see  what  a  tremendous  factor  milk  is  in  the  distribution  of  dis- 
ease, and  to  what  unnecessary  danger  we  subject  our  babies  in 
offering  them  this  food.  But  don't  forget  that  in  spite  of  all 
this,  cow's  milk  still  is  by  far  the  best  substitute  for  breast  milk 
that  we  have.  Cow's  milk  may  become  infected  in  different 
ways :  it  may  be  directly  infected  when  obtained  from  the  cow, 
but  this  is  rare.  About  2  percent  of  tuberculous  cattle  have 
involvement  of  the  udder,  and  in  these  the  milk  may  contain  as 
many  tubercle  bacilli  as  does  the  sputum  of  tuberculous  patients. 
Again,  the  cow  with  pulmonary  tuberculosis'  coughs  up  the  or- 
ganisms, swallows  them,  and  they  get  distributed  throughout 
the  manure  in  the  stable.  During  the  milking  they  are  whisked 
into  the  buckets,  and  these  buckets  of  milk  then  being  added 
to  others,  distribute  tuberculosis  throughout  the  community. 
Rosenau  quotes  a  study  of  market  milk  in  Chicago  in  1910 
which  showed  that  10.5  percent  of  144  specimens  examined  con- 
tained tubercle  bacilh,  as  did  16  percent  of  all  specimens 
of  butter  examined.  In  the  same  way  other  diseases  are 
distributed,  the  most  common  one  being  typhoid.  Wide- 
spread epidemics  of  this  disease  have  been  reported  in  all  parts 
of  the  world,  and  have  been  traced  absolutely  and  definitely  to 
the  milk  supply.  The  organisms  get  into  the  milk,  as  a  rule,  not 
so  much  from  a  case  of  active  typhoid  as  from  a  so-called  typhoid 
carrier  who  works  around  the  farm,  viz.,  a  man  in  perfect  health 
who  harbors  typhoid  organisms  in  his  excretions. 

How  are  we  going  to  avoid  these  dangers  in  feeding  our  babies? 
How  are  we  going  to  offer  babies  cow's  milk  and,  at  the  same 
time,  not  make  ourselves  Uable  to  the  terrible  accusation  that 
we  have  infected  our  babies  with  tuberculosis,  typhoid,  or  dysen- 
tery?   There  are  at  present  three  methods  at  our  disposal: 

a.  Pasteurization. 

6.  Demanding  of  certified  milk. 

c.  Boiling. 

I  am  going  to  speak  very  little  of  pasteurization,  because  if 
you  are  in  no  position  to  get  certified  milk,  I  doubt  whether  a 
State  pasteurization  law  would  be  a  great  success.     Indeed, 


MILK  159 

pasteurization  may  do  more  harm  than  good.  Do  you  remem- 
ber that  we  spoke  previously  of  the  changes  that  bacteria  cause 
in  milk;  that  when  they  attack  carbohydrate,  lactic  acid  is 
formed?  The  greatest  percentage  of  cases  of  spoiled  milk  result 
from  fermentation  and  formation  of  lactic  acid.  This  lactic 
acid  in  itself  is  not  harmful,  and  by  its  presence  not  only  may 
show  that  the  milk  has  been  improperly  handled,  but  also  may 
prevent  dangerous  organisms,  such  as  typhoid  or  dysentery, 
from  growing.  If  we  should  pasteurize  the  milk  back  on  the 
farm,  thus  killing  all  the  germs  that  produce  lactic  acid,  and 
then,  after  having  done  this,  we  should  permit  a  typhoid  or  a 
dysentery  bacillus  to  get  into  that  milk,  this  organism  would 
have  a  perfectly  clear  field  for  growth.  If,  on  the  other  hand, 
the  milk  were  unpasteurized  and  it  became  spoiled,  in  the  great 
majority  of  cases  the  lactic  acid  produced  might  prevent  the 
growth  of  the  more  deadly  organisms.  So  if  you  are  not  in  a 
position  to  keep  that  milk  absolutely  free  from  contamination 
to  the  time  of  its  deUvery,  I  would  not  unreservedly  recommend 
pasteurization. 

The  term  "certified  milk"  was  introduced  by  Dr.  Henry 
Coit,  of  Newark,  N.  J.  According  to  our  present  conception, 
certified  milk  is  simply  milk  of  the  highest  quality,  uniform  in 
composition,  obtained  Jrom  healthy  cows  under  the  supervision 
of  a  milk  commission.  I  should  advise  you  to  become  interested 
in  this  subject.  What  is  necessary  is  for  some  of  you  to 
form  a  committee  and  enter  into  a  contract  with  a  reliable  milk 
dealer.  The  dealer  must  allow  frequent  inspection  of  his  dairy 
and  frequent  analyses  of  the  milk.  The  cows  must  be  pro- 
nounced free  from  tuberculosis  by  a  reliable  veterinarian,  and 
must  show  a  negative  tuberculin  test.  They  must  be  free  from 
all  communicable  disease.  They  must  be  housed  in  clean, 
properly  ventilated  stables;  the  old  wooden  walls  must  give 
way  to  brick;  the  floors  must  be  sloping  to  allow  for  flushing 
and  to  prevent  the  accumulation  of  waste  and  manure  around 
the  stalls.  All  persons  coming  in  contact  with  the  milk  must 
be  free  from  the  germs  of  typhoid,  tuberculosis,  and  diphtheria, 
and  must  observe  scrupulous  cleanliness.  The  milk  must  be 
drawn  with  the  strictest  care;  the  cows  washed  before  milking; 
the  tail  tied  to  the  leg,  and  the  udders  cleaned.    The  attendants, 


160  INFANT   FEEDING    (CHICAGO   METHODS) 

dressed  in  white,  must  observe  great  cleanliness  during  the  milk- 
ing process.  The  milk  should  be  immediately  cooled,  placed  in 
sterilized  bottles,  and  kept  at  a  temperature  of  not  over  50°  F. 
until  delivered.  It  must  be  delivered  within  twenty-four  hours 
after  milking,  and  at  that  time  may  contain  no  more  than  10,000 
bacteria  per  cubic  centimeter.  I  should  certainly  advise  you, 
gentlemen,  to  take  some  interest  in  establishing  a  certified  milk 
dairy  in  this  neighborhood. 

Until  certified  milk  can  be  obtained,  however,  there  is  one 
method  that  remains  for  making  perfectly  safe  the  milk  that 
you  are  feeding  your  babies,  and  that  you  may  employ  right 
now — this  very  day — boil  your  milk!  In  the  olden  times — a 
few  years  ago — when  the  science  of  bacteriology  was  being 
developed,  it  was  thought  necessary  to  boil  and  reboil  the 
milk  in  order  to  kill  any  bacteria  that  it  contained,  and  in 
these  processes  changes  took  place  which  made  the  milk  a 
rather  dangerous  food.  Children  being  fed  this  way  frequently 
developed  scurvy.  Now  we  know,  however,  that  if  milk  simply 
is  brought  to  a  boil  and  boiled  gently  for  a  minute  or  two,  no 
such  danger  exists.  We  can  speak  with  absolute  assurance  as  to 
the  harmlessness  of  feeding  milk  so  treated.  Just  look  for  a 
moment  at  the  European  battle-fields.  The  men  of  France, 
Austria,  and  Germany  seem  to  be  pretty  good  fighting  men,  and 
every  one  of  them  who,  when  an  infant  was  not  fed  on  breast 
milk,  was  raised  on  boiled  milk.  In  those  countries  raw  milk 
is  unknown.  So  you  see  that  very  good  fighting  men  can  be 
raised  on  boiled  milk.  If  you  wish  to  make  yourself  entirely 
safe, — to  have  your  conscience  perfectly  free, — you  may  add  a 
little  orange-juice  to  the  diet  during  the  second  month,  and  with 
this  routine  I  can  assure  you  that  no  case  of  scurvy  ever  will 
develop  from  this  cause. 

In  the  discussion  of  boiled  milk  another  question  is  raised 
which  is  of  particular  interest  to  me,  for  if  was  in  Chicago  that 
a  very  important  problem  along  these  lines  was  solved.  The 
German  pediatrician,  Biedert,  described  curds  appearing  in  the 
baby's  stools^-curds  which  were  hard,  white,  and  very  much  like 
a  lima-bean  in  appearance.  He  said  these  curds  were  protein, 
and  used  them  as  evidence  of  the  indigestibility  of  casein.  This 
view  later  was  corroborated  by  other  observers.     The  new  Ger- 


MILK  161 

man  school,  however,  took  a  different  view  of  the  matter.  Using 
more  scientific  methods,  they  fed  children  casein  and  found 
hardly  any  increase  of  nitrogen  in  the  stools;  and  they  argued 
that  as  feeding  casein  causes  no  increase  in  nitrogen  in  the  stool, 
these  curds  could  not  be  protein.  American  observers  then  be- 
came interested,  and,  if  I  remember  correctly,  Talbot,  of  Boston, 
was  one  of  those  insisting  upon  the  fact  that  these  curds  did 
consist  of  casein.  The  Germans  rather  scorned  this  view,  and 
claimed  that  the  American  methods  were  inaccurate.  The 
Americans  replied  with  more  delicate  experiments,  using  sero- 
logical methods,  and  again  claimed  that  the  curds  were  casein. 
The  Germans  replied  that  the  methods  now  were  too  delicate, 
and  that  the  Americans  had  identified  the  small  amounts  of 
protein  that  were  present  in  the  intestinal  juices,  but  that  the 
main  structure  of  the  curd  was  fat.  The  controversy  waxed 
quite  warm,  and  was  finally  settled  by  Joseph  Brennemann,  of 
Chicago,  in  one  of  the  most  important  pieces  of  work  that  has 
been  done  in  the  field  of  pediatrics  in  America. 

Brennemann  studied  the  cases  coming  to  the  dispensary  of  our 
medical  college  at  home.  Northwestern  University  Medical 
School.  He  found  that  the  stools  of  many  infants  contained 
these  curds.  Careful  study  and  observation  showed  that  the 
curds  varied  from  day  to  day — some  days  being  present,  some 
days  absent.  Careful  questioning  showed  that  at  times  the 
mothers  boiled  the  milk,  at  times  they  didn't,  and  continua- 
tion of  the  study  revealed  the  extremely  interesting  fact  that  on 
the  days  when  milk  was  boiled  the  curds  disappeared  from  the 
stools.  When  the  milk  was  used  raw,  they  returned.  Here, 
then,  was  the  simple  solution  of  the  great  problem  that  had  been 
vexing  Europe  and  America.  On  the  continent,  where  raw  milk 
is  unknown,  the  men  never  had  even  seen  these  casein  curds, 
and,  sure  enough,  what  they  had  seen  were  curds  of  fat.  In  this 
country,  with  the  previously  invariable  use  of  raw  milk,  we  saw 
the  true  casein  curd.  So  you  see  that  the  whole  controversy  was 
caused  by  our  discussing  and  describing  different  things,  and  I 
can't  help  thinking  that  probably  many  of  the  great  problems 
in  pediatrics  may  be  due  to  this  same  fundamental  error— de- 
scribing and  talking  about  dif  event  things.  The  formation  of 
these  curds  is  purely  a  physical  process.  It  has  nothing  to  do 
11 


162  INFANT   FEEDING    (CHICAGO   METHODS) 

with  digestion.  They  will  form  in  the  bottle  as  well  as  in  the 
stomach,  and  are  due  not  to  digestive  trouble,  but  simply  to 
shaking  of  the  milk  after  a  ferment  has  been  added.  If  we  add 
a  ferment  to  milk  in  a  bottle  and  shake  it  violently,  hard,  tough 
curds  form.  The  same  holds  true  in  the  stomach.  If,  on  the 
other  hand,  we  introduce  the  milk  into  the  small  intestine  by 
means  of  a  Hess  tube,  thus  saving  it  the  mechanical  shaking  in 
the  stomach,  none  of  these  abnormal  curds  form.  The  problem 
of  this  curd  formation,  then,  is  simply  one  of  physics,  and  is  not 
of  particular  interest  to  us  from  the  standpoint  of  physiology. 

To  conclude:  remember,  first,  the  fundamental  differences 
between  cow's  milk  and  breast  milk;  remember  that  these 
differences  are  not  only  in  the  quantity  of  the  individual  ingre- 
dients, but  also  in  quahty,  and  that  with  no  simple  means  at 
our  disposal  can  we  make  cow's  milk  identical  to  breast  milk. 
Remember  that  when  cow's  milk  is  not  properly  handled,  bac- 
teria grow  in  it  at  a  tremendous  pace.  In  their  growth  they 
may  cause  one  of  two  changes.  If  they  attack  the  carbohy- 
drates, they  produce  acids,  this  process  being  known  as  fermen- 
tation; if  they  attack  protein,  they  produce  alkaline  products, 
this  process  being  known  as  putrefaction.  I  urge  you,  gentle- 
men, not  to  forget  these  two  processes :  fermentation  and  'putre- 
faction.   We  shall  hear  them  time  and  time  again. 

Breast  milk  being  high  in  sugar  and  low  in  protein  favors 
fermentation.  Cow's  milk  being  high  in  protein  and  low  in 
sugar  favors  putrefaction. 

Remember,  however,  that  the  quantity  of  bacteria  is  not  so 
important  as  the  quahty,  and  that  milk  which  may  be  swarming 
with  lactic  acid  germs  is  not  nearly  so  deadly  as  that  which 
may  contain  smaller  numbers  of  typhoid  or  tubercle  or  dysen- 
tery bacilli.  If  you  wish  to  have  a  clear  conscience  in  feed- 
ing your  babies;  if  you  wish  to  feel  certain  that  you  have  not 
been  responsible  for  a  death  from  tuberculosis  or  typhoid  or 
dysentery,  you  must  see  that  the  milk  is  pure.  You  have  three 
methods  at  your  disposal :  The  one  I  urge  upon  you  is  to  hoil 
the  milk.  In  doing  this  you  will  positively  work  no  injurj'"  to 
the  child;  you  will  change  the  protein  so  that  no  hard  curds 
will  appear  in  the  stool,  and  you  will  protect  the  child  from  the 
deadly  milk-borne  diseases. 


LECTURE  n 
DIGESTION  OF  MILK 

Gentlemen:  In  the  last  lecture  we  discussed  the  subject  of 
milk.  Today  we  take  up  "milk  and  the  baby,"  considering 
carefully  the  changes  that  each  causes  in  the  other.  We  shall 
dwell  upon  the  points  in  practical  physiology  that  we  absolutely 
must  know  in  order  to  understand  what  is  to  come.  Even  if 
some  of  them  seem  a  little  abstruse  or  impractical,  nevertheless 
I  urge  you  to  follow  me,  for  you  will  find  that  I  am  telling  you 
nothing  that  will  not  later  be  of  importance.  I  am  going  to 
quote  freely  from  Langstein  and  Meyer,  which  we  should  use  as 
our  text-book. 

The  old  idea  of  the  digestion  of  protein  was  that  in  this  process 
the  protein  simply  became  soluble.  Now  we  know  that  protein 
digestion  is  a  far  more  complicated  process,  the  protein  literally 
being  torn  to  pieces  by  the  ferments  of  the  digestive  tract.  The 
individual  fragments  are  called  amino-acids.  In  the  process  of 
assimilation,  these  amino-acids  are  put  together  again  and  built 
into  the  structure  of  the  baby's  tissue.  Protein  digestion  be- 
gins in  the  stomach  and  is  completed  in  the  intestine. 

In  the  intestine,  protein  performs  an  important  function; 
viz.,  its  digestion  requires  large  quantities  of  alkaline  intestinal 
juice,  and  in  this  way  protein  becomes  associated  with  the  for- 
mation of  an  alkaline  reaction  in  the  intestine.  Practically  all 
the  protein  is  absorbed  from  the  gastro-intestinal  tract,  par- 
ticularly when  the  milk  is  boiled.  With  raw  milk  large  casein 
curds  escape  digestion,  but  with  boiled  milk  very  little  nitrogen 
leaves  the  body  by  way  of  the  stool.  And  this  nitrogen  does  not 
necessarily  have  to  come  from  the  protein  of  the  food,  but  may 
come  also  from  the  protein  of  the  intestinal  juices,  of  the  in- 
testinal bacteria,  and  of  the  intestinal  epitheUum.  Once  past 
the  digestive  tract  and  into  the  body,  this  food  has  three  im- 
portant duties: 

163 


164  INFANT  FEEDING   (CHICAGO  METHODS) 

a.  It  will  replace  protein  that  has  been  lost  from  the  body. 

h.  It  suppUes  substance  to  the  tissues  to  satisfy  growth. 

c.   It  can  be  used  by  the  tissues  for  energy. 

It  is  interesting  that  the  amount  of  protein  retained  in  the 
body  does  not  depend  markedly  upon  the  amount  offered,  the 
child  retaining  approximately  the  same  amount  of  nitrogen 
whether  fed  on  the  low  protein  breast  milk  or  the  high  protein 
cow's  milk.  When  protein  leaves  the  body,  it  is  excreted  prac- 
tically entirely  through  the  urine.  About  60  to  80  percent  of 
it  appears  as  urea  and  the  remainder  as  ammonia  and  other 
waste-products. 

FAT 

Like  protein,  fat  digestion  begins  in  the  stomach.  There 
perhaps  25  percent  of  it  is  split  up,  the  rest  being  digested  by  the 
ferments  of  the  intestine.  Unlike  protein,  however,  some  fat 
normally  appears  in  the  stool.  Whether  this  fat  has  been  taken 
into  the  body  and  then  excreted  into  the  large  intestine,  or 
whether  it  simply  passes  along  the  intestinal  tract  undigested, 
we  do  not  know,  but  the  fact  remains  that  approximately  1  to 
10  percent  of  the  fat  taken  by  the  baby  will  reappear  in  the 
stool.  This  fat  is  not  necessarily  in  the  same  form  as  it  was 
when  the  baby  drank  it.  It  may  appear  in  three  different  ways, 
and  these  ways,  gentlemen,  I  urge  you  to  note,  because  we  shall 
hear  of  them  later.     It  may  exist  as : 

(1)  Ordinary  neutral  fat.  This  is  the  simple  fat  that  was 
in  the  milk. 

(2)  Fat-soaps.  I  won't  bother  you  with  the  chemistry  of 
the  formation  of  soaps,  but  in  a  crude  general  way  remember 
that  fat,  when  it  joins  alkalis,  such  as  calcium  and  magnesium, 
forms  a  soap.  This  is  not  the  absolutely  correct  chemical  com- 
bination, but  it  will  suffice. 

(3)  Fatty  acids.  These,  in  contrast  to  soaps,  are  simply  fat 
in  combination  with  an  acid.  Again,  this  is  not  strictly  chemi- 
cally correct,  but  it  will  do. 

So  you  see  when  the  intestine  is  alkaline,  soaps  are  formed, 
and  when  the  intestine  is  acid,  the  soaps  disappear  and  the  fat 
becomes  changed  to  a  fatty  acid. 

Most  of  the  fat  that  passes  the  digestive  tract  is  either  burned 


DIGESTION   OF  MILK  165 

in  the  body  or  else  is  stored  in  the  subcutaneous  tissues  and  the 
liver.  Fat,  in  contrast  to  protein,  is  not  an  absolute  essential 
to  the  diet.  Some  babies  thrive  on  buttermilk  or  on  skimmed 
milk,  with  practically  no  fat.  However,  clmical  observation 
would  suggest  that  these  children  have  a  lessened  degree  of 
immunity  to  infection  than  those  on  higher  fat  diets. 


CARBOHYDRATES  OR  SUGARS 
In  taking  up  the  subject  of  carbohydrates,  we  consider  perhaps 
the  most  interesting  element  of  food.     Carbohydrates  exist  in 
nature  in  three  different  forms: 

(1)  Complex  carbohydrates,  of  which  starch  is  an  example. 

(2)  Less  complex  forms,  known  as  disaccharids,  of  which 
lactose  (milk-sugar),  saccharose  (cane-sugar),  and  maltose  (malt- 
sugar)  are  examples. 

(3)  Simple  forms,  of  which  glucose  or  grape-sugar  is  a  good 
illustration. 

It  is  interesting  that  the  body  can  use  carbohydrate  only  in 
its  simplest  form,  viz.,  that  form  which  glucose  represents.  If 
we  should  inject  a  solution  of  lactose  (milk-sugar)  under  the 
skin,  this  very  same  lactose  would  pass  right  through  the  body, 
would  be  absolutely  untouched  by  the  body  tissues,  and  would 
be  excreted  in  the  urine  as  lactose.  This  holds  true  for  prac- 
tically all  the  other  more  compUcated  sugars,  with  the  one  ex- 
ception of  maltose.  In  some  mysterious  way  the  cells  of  the 
body  seem  to  have  the  faculty  of  using  maltose.  So  you  see 
that  the  process  of  digestion  of  carbohydrate  is  simply  a  means 
by  which  more  complicated  sugars  are  split  down  to  the  simple 
ones — a  means  to  adapt  all  forms  of  carbohydrate  to  the  use  of 
the  body  tissues.  In  this  splitting  process,  we  should  remember 
the  different  stages  through  which  a  complex  carbohydrate  like 
starch  passes.  The  first  product  is  a  substance  called  dextrin, 
which  is  very  much  like  thoroughly  browned  flour.  The  next 
step  is  the  formation  of  maltose,  and  the  last  step,  the  forma- 
tion of  the  simple  sugars,  such  as  glucose.  That  you  may  have 
a  clearer  picture,  let  me  remind  you  that  the  simple  sugar  glu- 
cose is  composed  of  C6H12O6;  the  disaccharids,  meaning  milk- 
sugar,  malt-sugar,  and  cane-sugar,  are  composed  roughly  of  two 


166  INFANT  FEEDING    (CHICAGO   METHODS) 

of  these  simple  sugars  fastened  together,  and  the  complicated 
carbohydrates,  such  as  starches,  are  composed  of  a  great  many 
of  them  bound  together  in  different  fashions. 

Just  as  with  other  food  substances,  most  of  the  carbohydrate 
digestion  goes  on  in  the  intestine.  Here  simple  sugars  are 
formed  and  practically  all  absorbed.  In  the  normal  baby  one 
rarely  finds  any  carbohydrate  in  the  stool.  One  exception  may 
be  made  in  a  child  receiving  a  large  amount  of  starch.  If  the 
starch  is  not  thoroughly  digested,  it  will  appear  in  the  stools. 

Having  passed  the  intestinal  mucous  membrane,  the  carbo- 
hydrate enters  the  blood  and  is  stored  in  the  liver  and  muscles 
as  glycogen.  From  these  great  storehouses  the  amount  of  sugar 
in  the  blood  is  kept  at  practically  uniform  composition,  viz., 
0.1  percent.  The  end-products  formed  by  burning  are  chiefly 
carbon  dioxid  and  water.  The  carbohydrate  is  practically  all 
burned,  and  never  normally  appears  in  the  urine  imless  very 
large  quantities  are  given. 

It  is  well  to  remember  that  a  child  has  a  very  great  tolerance 
for  carbohydrate,  apparently  needing  much  more  in  proportion 
to  his  body-weight  than  does  an  adult.  Just  take  this  example, 
for  instance:  A  baby  weighing  10  pounds  will  drink  approxi- 
mately 800  c.c,  of  breast  milk — almost  a  quart.  In  this  he 
gets  56  grams  of  lactose — almost  2  ounces.  If  we  wish  to  feed 
an  adult  weighing  140  pounds  the  same  amount  of  sugar  in  pro- 
portion to  his  weight,  we  would  have  to  feed  him  800  grams  a 
day — ^almost  28  ounces.  So  you  see  what  need  the  child  has  for 
sugar.  Indeed,  from  the  study  of  infant  nutrition  and  disease 
we  are  learning  much  of  the  value  of  carbohydrate  and  the 
variety  of  functions  it  performs. 

a.  First  and  foremost,  sugars  supply  energy  to  the  tissues. 
The  baby  moves  and  cries  and  performs  all  his  daily  work 
chiefly  from  the  energy  supplied  by  the  carbohydrate. 

b.  Interesting  and  not  thoroughly  explained  is  the  fact  that 
carbohydrate  seems  to  save  tissue  protein.  If  we  feed  a  certain 
amount  of  sugar,  the  baby  seems  to  live  on  this  and  use  up  less 
of  his  body  protein. 

c.  Carbohydrate  is  related  to  the  fat.  If  the  body  is  not  sup- 
plied with  enough  sugar,  the  fat  of  the  food  becomes  poisonous 
and  abnormal  split  products  appear  in  the  urine.     When  the 


DIGESTION   OF  MILK 


167 


carbohydrate  is  increased,  these  toxic  products  disappear.  The 
old  German  clinician,  Naunyn,  described  this  in  the  striking 
sentence:  "The  fat  burns  in  the  fire  of  the  carbohydrate." 
Just  remember  that  sentence,  gentlemen,  "  The  fat  bums  in  the 
fire  of  the  carbohydrate,"  and  you  will  have  a  striking  picture  of 
fat  and  carbohydrate  metabolism. 

d.  In  contrast  to  fat,  sugar  cannot  be  replaced.  Rosenstern, 
one  of  Finkelstein's  assistants,  in  interesting  experiments  showed 
that  if  sugar  is  removed  entirely  from  the  diet,  the  baby  will  not 
thrive,  and  he  proved  conclusively  that  a  baby  to  hve  must  have 
a  definite  minimum.  So  in  contrast  to  fat,  sugar  is  absolutely 
essential  to  life. 

e.  We  are  begimiing  to  learn  of  an  important  relation  that 
carbohydrates  have  to  water  in  the  body.  This  point  is  not 
absolutely  established,  some  scientists  saying  that  we  have  not  as 
yet  proved  our  point;  but  clinical  evidence  is  very  strong,  and 
it  is  on  the  basis  of  this  clinical  evidence  that  I  ask  you  to  re- 
member that  carbohydrates  help  the  baby  retain  water.  The 
following  curve  illustrates  the  observations  which  led  us  to  these 
conclusions  (Fig.  1): 


Dav8. 

I 

2 

3 

4 

5 

6 

6 
4 

2 
e  lbs, 

>• 

/ 

A* 

/ 

^ 

y 



"A" 


Fig.  1.— (From  Langstein  and  Meyer.) 


If,  at  point  "A,"  one  should  add  a  small  amount,  viz.,  two  to 
three  teaspoons,  of  a  simple  carbohydrate,  to  the  bottle,  fre- 
quently in  one  to  two  days  the  weight  jumps  up  many  ounces. 
How  are  we  to  explain  this  abrupt  rise  in  the  curve?  A  baby 
cannot  gain  several  ounces  from  a  few  teaspoons  of  food. 
There  is  not  enough  protein,  not  enough  fat,  not  enough  carbo- 
hydrate in  a  few  teaspoons  to  make  several  ounces.    The  logical 


168 


INFANT   FEEDING    (CHICAGO   METHODS) 


conclusion  is  that  this  gain  must  be  due  to  water.  A  child  is 
like  a  sponge,  absorbing  water  into  his  tissues  and  excreting 
it  again  very  readily.  Again,  the  removal  of  a  small  amount  of 
sugar  from  this  diet  may  lead  to  a  sharp  drop  of  five  to  six  ounces. 
/.  Sugars  have  an  interesting  relation  to  body  temperature: 

(1)  If  the  body  is  markedly  cooled,  glycogen  seems  to  dis- 
appear from  the  muscles. 

(2)  The  following  temperature  curve  will  illustrate  this  from 
a  clinical  standpoint  (Fig.  2) : 


99' 
98° 
97" 

f 

^  ^ 

^  ^ 

_. 

,_ 

^  ^ 

^  ^ 

•r- 

• 

r 

2 

o/o 

4 

o/ 

) 

• 

Fig.  2. — (From  Langstein  and  Meyer.) 

This  child,  with  only  2  percent  sugar  in  his  diet,  may  have  had 
a  subnormal  temperature  for  several  days.  If  we  increase  the 
sugar  to  4  percent,  the  temperature  may  rise  to  normal. 


MINERAL  MATTER 

Gentlemen,  the  mineral  matter  in  baby's  food  has  long  been 
overlooked.  Indeed,  even  now  the  door  has  barely  opened,  but 
visions  and  dreams  perhaps,  begin  to  suggest  the  coming  im- 
portance of  mineral  metabolism.  One  may  almost  say  that 
physiologists  are  learning  from  the  pediatricians.  The  baby  is 
the  simplest  of  all  organisms  to  study.  He  is  untouched  by 
disease;  his  food  is  the  simplest  of  all  foods — can  be  analyzed 
and  absolutely  controlled ;  and  to  get  correctly  the  total  urine 
and  daily  stools  in  twenty-four  hours  is  not  a  very  difficult  task. 
Hence  the  study  of  the  baby  has  increased  our  knowledge  de- 
cidedly in  some  of  the  fields  of  physiology. 

Of  mineral  matter,  breast  milk  has  0.2  percent;  cow's  milk, 


DIGESTION   OF  MILK  169 

0.76  percent.     You  see  that  cow's  milk  has  almost  four  times  the 
salt  content  of  breast  milk. 

Strange  that  in  our  studies  we  have  so  long  overlooked  these 
differences.  The  splendid  researches  of  Ludwig  F.  Meyer  only 
relatively  recently  have  been  responsible  for  bringing  them  to 
our  attention.  Like  other  foods,  salts  are  absorbed  chiefly  from 
the  intestines.  In  the  body  they  perform  many  functions,  and 
then  leave  through  the  kidney  and  bowel.  Through  the  kidneys 
most  are  excreted;  through  the  intestines  calcium,  magnesium, 
and  iron  leave.  Of  course,  we  cannot  say  whether  the  calcium, 
magnesium,  and  iron  found  in  the  stool  have  been  absorbed  into 
the  body  and  thrown  out  again,  or  whether  they  have  simply 
passed  unabsorbed  along  the  child's  digestive  tract;  but  we  do 
know  that  we  find  these  salts  in  the  stool.  In  passing,  let  me 
call  your  attention  to  the  calcium: 

One  Quart 

Breast  Milk                               Cow's  Milk 
Calcium 0.42  gram         Calcium 1.72  grams 

This  preponderance  of  calcium  in  cow's  milk  is  an  important 
factor  in  making  the  intestine  alkaline. 

In  the  normal  baby  salts  have  a  relation  to  protein,  and  for 
every  definite  amount  of  protein  that  the  child  absorbs  a  corre- 
sponding amount  of  salt  is  retained.  This  relation  is  far  more 
definite  in  the  baby  on  the  breast  than  in  the  one  on  the  bottle, 
and  in  disturbances  of  the  latter  often  far  more  mineral  is  lost 
than  is  nitrogen.  This  improper  relation  of  salt  to  protein  in  the 
artificially  fed  baby  may  feature  in  some  of  the  disturbances. 

Gentlemen,  I  don't  want  to  bother  you  too  much  with  chem- 
istry, but  let  me  give  you  one  httle  glimpse  into  the  possibiUties 
of  salt  metabolism.  Suppose  we  , 

take  a  simple  salt  like  calcium  ^"  ^'''^ 

chlorid;  suppose  that  salt  is  in- 
troduced into  the  intestine.    In 

the  intestine  it  is  split  up  into  «  j^^  4^  -»  Stool 

calcium  and  chlorin.     We  just  p-    3 

have    learned    that    chlorin    is 

excreted  chiefly  in  the  urine;   calcium,  in  the  stool.    We  may 
picture  this  by  the  accompanying  illustration  (Fig.  3). 


170 


INFANT   FEEDING    (CHICAGO   METHODS) 


Chlorin  cannot  leave  the  body  alone,  but  must  leave  in  com- 
bination with  some  other  salt,  usually  sodiimi.  The  calcium 
makes  other  combinations  in  the  intestines.  Thus,  feeding  a 
simple  substance  like  calcium  chlorid  forces  sodium  out  of  the 
body  through  the  urine.  This  is  a  simple  conception,  but  see 
what  tremendous  possibilities  open  to  us!  Just  picture  to  your- 
selves all  the  different  salts  of  the  baby's  diet  pursuing  their 
individual  courses  through  his  body.  See  these  possibilities! 
We  barely  are  beginning  to  grasp  them.  How  utterly  in  the 
dark  are  we  as  to  the  actual  effects  upon  the  child's  organism 
of  the  compUcated  mixtures  that  we  are  wont  to  prescribe!    We 


n  lb 

8   02 

11  lb 

8  oz 
10  lb 

98° 

/ 

V 

'^  \    ^"^ 

A 

"  \"^  V-'--'"  -^  V^'^  ^^^ 

\ 

VA 

\ 

\ 

\ 

.>r\  ,A./s 

Fig.  4. — Drop  in  weight  and  temperature  following  salt  withdrawal. 
(From  Langstein  and  Meyer.) 

are  barely  at  the  beginning  of  understanding  the  true  effects 
of  our  simple  combinations,  and  you  can  see  what  enormous 
differences  absolutely  unknown  to  us  must  there  be  in  the  effects 
upon  the  child's  body  of  the  markedly  different  salt  contents  of 
breast  milk  and  of  cow's  milk. 

Like  protein,  water,  and  carbohydrates,  minerals  are  essential 
to  life,  and  removal  of  them  results  in  rapid  death.  The  fasci- 
nating experiments  of  Jacques  Loeb  show  that  not  only  are 
minerals  absolutely  essential  to  life,  but,  if  they  are  not  present 
in  the  body  in  certain  proportions,  they  may  exert  toxic  in- 
fluences. The  surgeons  make  use  of  these  principles  in  their 
so-called  balanced   salt   solutions.     Like   carbohydrate,   salts 


DIGESTION   OF  MILK  17^ 

seem  to  have  definite  relation  to  body  weight  and  temperature 
(Fig.  4). 

The  removal  of  salts  at  A  results  in  a  drop  of  temperature  and 
a  marked  loss  of  weight.  The  most  important  of  all  salts  in 
causmg  these  effects  is  sodium.  Again,  in  chronic  undernutri- 
tion, with  deficiency  of  salt  in  the  diet,  the  temperature  may  be 
consistently  subnormal,  and  feeding  a  child  in  this  stage  about  a 
dram  of  sodium  chlorid  may  cause  a  marked  rise  in  temperature 
with  fever.  ' 

WATER  METABOLISM 

The  child's  tissues  are  somewhat  richer  in  water  than  the 
adult's.  In  a  quart  of  breast  milk  a  day,— a  quart  being 
equal  to  1000  c.c.,— he  drinks  885  c.c.  of  water.  Just  see  the 
percentage  of  water  in  baby's  diet,— 885  parts  to  every  1000,— 
or,  to  put  it  differently:  an  adult  uses  approximately  one-half 
ounce  of  water  for  every  pound  that  his  body  weighs,  while 
the-  child  uses  between  two  and  three— about  four  times  the 
quantity  of  the  adult.  Like  the  othfer  food-stuffs,  water  is  ab- 
sorbed chiefly  from  the  small  intestine.  It  is  stored  mainly  in 
the  muscles  and  normally  leaves  the  body  about  60  percent 
through  the  urine  and  about  40  percent  through  the  lungs  and 
skin. 

Like  carbohydrate,  salts  have  a  definite  relation  to  water 
(Fig.  5). 

If,  at  A,  we  add  a  teaspoon  of  salt  to  the  diet,  the  baby's 
weight  rises  sharply.  The  inexperienced  physician  and  the 
happy  mother  might  exclaim:  "At  last  we  have  found  the 
proper  diet !  The  child  finally  is  gaining !"  But,  unfortunately, 
the  excretion  of  this  salt  is  accompanied  by  just  such  a  precipi- 
tate loss  as  there  was  previously  a  gain.  The  weight  comes 
down  exactly  to  where  it  was  before  the  salt  was  added,  and 
now  we  rather  ruefully  learn  that  this  great  gain  was  not  in 
true  tissue  substance,  but  was  only  in  the  water-content  of  the 
body. 

MILK  IN  THE   GASTRO-INTESTINAL  TRACT 

Gentlemen,  we  have  considered  the  individual  elements  of 
the  milk.  We  have  studied  them  in  the  gastro-intestinal  tract; 
we  have  followed  them  through  the  body;  we  have  seen  them 


172 


INFANT   FEEDING    (CHICAGO   METHODS) 


in  their  excretion.     Let  us  pause  for  a  moment  and  look  at  the 
milk  as  a  whole. 


Fig.  5. — Gain  in  weight  following  addition  of  salt  to  diet.     (From  Lang- 
stein  and  Meyer.) 

In  the  stomach  two  important  changes  take  place:   the  pro- 
tein, due  to  the  rennet,  coagulates,  and  the  milk  separates  into 


DIGESTION   OF  MILK  173 

curd  and  whey.  You  remember  that  the  curd  consists  of  the 
casein,  which,  in  its  formation,  ensnares  some  fat.  In  this 
process  much  of  the  calcium  is  dragged  out  of  the  whey  and 
joined  in  chemical  combination  to  the  casein;  so  casein  in  con- 
nection with  the  base  calcium  becomes  a  powerful  agent  for 
making  the  intestine  alkaline.  The  whey,  you  will  remember, 
represents  the  water-soluble  elements  of  the  milk;  i.  e.,  the 
water,  salts,  sugar,  and  the  albumins  and  globulins.  This 
quickly  leaves  the  stomach.  The  casein  curd  with  the  en- 
trapped fat  may  remain  several  hours  to  be  thoroughly  digested. 
This  interesting  little  point  in  physiology  explains  the  useless- 
ness  of  following  the  tables  which  older  scientists  with  great 
pride  and  perseverance  built  for  us,  viz.,  feeding  the  child  at 
definite  ages,  food  in  proportion  to  the  capacity  of  his  stomach. 
As  a  matter  of  fact,  because  the  whey  leaves  the  stomach  so 
rapidly  we  often  feed  the  baby  more  than  one  might  imagine, 
and  we  may  disregard  entirely  these  older  tables.  You  see  we 
have  at  hand  a  means  for  hastening  or  retarding  the  emptying  of 
the  stomach.  A  mixture  high  in  whey  will  leave  the  stomach 
rapidly;  a  mixture  high  in  casein  and  fat  will  leave  slowly,  and 
so,  by  altering  our  mixtures,  we  can  greatly  influence  gastric 
motility. 

In  the  intestine  the  milk  meets  the  various  digestive  fer- 
ments. The  bile  makes  the  fat  soluble.  Then  the  feipnents  of 
the  pancreas  and  the  intestinal  glands,  aided  by  the  bile,  seize 
all  the  fat,  carbohydrate,  and  protein,  and  tear  them  down  to 
their  fundamental  elements.    These  then  leave  the  intestine. 


THE  STOOLS 

The  above  in  a  very  superficial  way  describes  the  digestion 
of  the  milk.  Just  what  remains  in  the  stool?  In  the  stool 
are — 

a.  Great  quantities  of  bacteria.  I  put  these  bacteria  first 
to  impress  you  with  their  importance.  Up  to  the  present, 
in  infant  feeding,  these  bacteria  have  be^n  almost  overlooked 
although  they  may  constitute  16  to  18  percent  of  the  stool. 
You  see  the  possibilities  for  bacterial  action  existing  in  the  intes- 
tine.    Normally,  the  organisms  live  only  in  the  large  intestine, 


174  INFANT   FEEDING    (CHICAGO   METHODS) 

the  upper  intestine  being  sterile;  but,  under  conditions  of  which 
we  shall  hear  later,  they  leave  their  home,  extend  up  to  the  small 
intestine,  and  flourish  there.  Why  they  normally  remain  only 
in  the  large  intestine  and  do  not  thrive  in  the  upper  bowel  is  not 
absolutely  known.  Some  men  claim  that  the  duodenum,  either 
by  its  juices  or  by  the  properties  of  its  cells,  is  able  to  exert  a 
strong  bactericidal  influence.  Kendall  has  suggested  to  me  that, 
due  to  the  rapid  absorption  of  food-stuffs,  bacteria  may  not 
thrive  in  the  upper  intestine,  as  no  food  remains  for  them.  Prob- 
ably both  factors  are  of  importance. 

In  the  large  intestine  two  different  groups  of  bacteria  exist: 
those  Uving  chiefly  on  protein,  attacking  this  protein,  and  caus- 
ing putrefaction  and  alkah  formation;  those  living  chiefly  on 
carbohydrate,  attacking  the  sugars  and  causing  fermentation 
and  acid  formation. 

Gentlemen,  in  the  last  lecture  you  heard  of  the  importance 
of  these  two  processes,  fermentation  and  putrefaction.  Just  as 
readily  as  in  the  milk  that  stands  at  the  doorstep,  do  these 
activities  proceed  in  the  child's  intestinal  tract;  but  here  we 
have  them  perfectly  under  control.  Feeding  protein  calls  forth 
the  putrefactive  organisms;  feeding  carbohydrate  calls  those 
producing  fermentation.  Remember  that  putrefaction,  with 
resulting  alkaline  change,  slows  down  intestinal  peristalsis  and 
leads  to  an  alkaline,  foul-smelhng  stool.  On  the  other  hand, 
fermentation  with  resulting  acid  formation  leads  to  increased 
peristalsis  and  to  watery,  greenish,  sour-smelling  diarrheal  stools. 
I  urge  you  under  no  circumstances  to  forget  that  protein  putre- 
fies;  carbohydrate  ferments. 

h.  Besides  bacteria,  the  stool  consists  of  unabsorbed  food- 
stuffs. 

(1)  Protein,  we  learned,  rarely  appears  normally  in  any  appre- 
ciable quantity  unless  raw  milk  is  given. 

(2)  Fat  is  concerned  somewhat  in  the  actual  structure  of  the 
stool.  Feeding  skimmed  milk  may  result  in  thin  bowel  move- 
ments with  mucus  and  small  amounts  of  solid  material ;  increas- 
ing the  fat  in  the  diet  may  give  rise  to  a  formed  stool.  It  is  the 
fat  in  the  form  of  soaps  which  has  most  influence  on  stool 
structure. 

(3)  Like  protein,  httle  carbohydrate  is  found  normally  except 


DIGESTION   OF  MILK  175 

in  those  cases  where  much  starch  is  fed,  this  starch  passing  down 
the  intestinal  tract  undigested. 

(4)  The  salts  are  of  great  importance.  Calcium,  for  instance, 
by  its  insolubility  in  water,  gives  bowel  movements  of  dry, 
alkaline  nature. 

c.  Besides  bacteria  and  food  substances,  there  are  secondary 
products.  Protein,  as  you  remember,  calls  forth  alkahne  intes- 
tinal juice  rich  in  albumin.  Secondly,  any  protein  that  remains 
in  the  intestine  unabsorbed  will  be  attacked  by  the  putrefactive 
bacteria,  with  resulting  alkaline  products.  In  the  same  way  any 
unabsorbed  carbohydrate  will  ferment  into  acid  products.  The 
amount  of  fermentation  of  this  carbohydrate  we  can  influence 
markedly  by  the  nature  of  carbohydrate  we  use.  Bacteria 
do  not  attack  readily  the  comphcated  carbohydrates,  such  as 
starches  and  dextrins.  When  we  feed  starch  or  dextrin  to  a 
baby,  this  carbohydrate  is  changed  by  the  digestive  processes 
slowly  to  the  simpler  sugars,  and  these  simpler  sugars;  as  they 
are  formed  in  small  amounts,  are  absorbed  through  the  upper 
intestine  before  the  bacteria  attack  them.  Thus  complex  carbo- 
hydrates, such  as  starch  and  dextrin,  are  normally  rather  con- 
stipating. The  lower  carbohydrates,  such  as  milk-sugar  and 
glucose,  are  readily  attacked.  When  a  child  receives  a  large 
quantity  of  one  of  the  latter  some  of  the  sugar  may  reach  the 
region  where  intestinal  bacteria  are  flourishing,  and  fermenta- 
tion, acid  formation,  and  diarrhea  result.  Clinical  observation 
suggests  that  the  fermentation  of  these  sugars  is  influenced  by 
different  factors: 

(a)  Feeding  the  baby  whey  of  cow's  milk  seems  to  increase 
the  degree  of  fermentability  of  the  sugar. 

(6)  An  increased  amount  of  protein  with  its  putrefying  alka- 
line-forming properties  makes  the  sugar  less  fermentable. 

(c)  The  condition  of  the  intestine  is  of  great  importance: 

(1)  A  perfectly  healthy,  intact  mucous  membrane  will  be  able 
to  keep  bacterial  growth  under  control  and  prevent  a  marked 
degree  of  fermentation. 

(2)  A  diseased  intestine  may  not  be  able  to  combat  a  fermen- 
tation induced  by  high  sugar  feeding. 

You  see,  gentlemen,  why  I  am  dwelling  upon  these  subjects. 
The  condition  of  the  baby's  stool  depends  absolutely  upon  you. 


176  INFANT  FEEDING   (CHICAGO  METHODS) 

You  have  at  your  disposal  the  means  of  making  the  stool  alka- 
line, constipated,  and  hard,  or  acid,  diarrheal,  and  watery. 
There  is  no  mystery  about  the  process;  the  explanation  is 
simple;  the  means  are  at  hand.  Feeding  a  baby  high  protein, 
by  inducing  putrefactive  change,  by  calling  forth  large  amounts 
of  alkaUne  intestinal  juices,  by  bringing  down  large  amounts 
of  the  base,  calcium,*  in  connection  with  the  casein,  produces 
constipated,  hard,  soapy  stools.  Feeding  large  amounts  of 
sugar,  by  inducing  fermentation,  with  the  resulting  formation  of 
various  irritating  acids,  leads  to  diarrheal  acid  stools,  DonH 
forget  these  important  factors. 

Just  one  word  about  the  energy  of  foods. 


ENERGY  OF  FOODS 

In  the  science  of  physics  the  term  "calorie"  is  used.  This  is 
purely  scientific,  and  means  the  amount  of  heat  or  energy  re- 
quired to  raise  1  gram  or  1  kilogram  of  water  one  degree  (30 
grams  are  an  ounce).  The  older  physicists  investigated  the 
energy  content  of  various  food-stuffs,  and  in  their  investiga- 
tions learned — 

1  ounce  of  protein  represents  about  120  calories. 

1  ounce  of  carbohydrate  represents  approximately  120  calories. 

1  ounce  of  fat  represents  approximately  270  calories. 

This  is  pure  physics.  It  was  due  to  the  investigations  of  the 
children's  specialist,  Heubner,  in  connection  with  the  physiol- 
ogist, Rubner,  that  these  physical  studies  were  applied  to  infant 
feeding.  They  showed  that  a  normal  hohy,  to  thrive  and  gain, 
requires  for  the  first  six  months  approximately  45  calories  for 
every  pound  of  his  body  weight.  For  example,  a  baby  weighing 
six  pounds  requires  about  270  calories.     From  these  studies  has 

*  Since  delivering  these  lectures  the  writer  has  read  the  fascinating  work 
of  C.  H.  Clowes,  Jour,  of  Phys.  Chem.,  1916,  xx,  407,  in  regard  to  emul- 
sions. He  has  shown  that  the  addition  of  salts  of  calcium  to  a  mixture  of 
oil  in  water,  as,  for  example,  cream,  will  promote  the  change  of  this  mixture 
to  an  entirelj'  different  type,  namely,  an  emulsion  of  water  in  oil,  as  butter. 
The  author  does  not  know  if  these  studies  have  as  yet  been  appUed  to  nutri- 
tional disturbances.  This  effect  of  calcium  salts  may  possibly  be  equally 
important,  as  regards  causing  constipation,  as  the  effect  of  calcium  as  an 
alkali. 


ENERGY   OF   FOODS  177 

developed  the  caloric  system  of  feeding  first  advocated  by  Heub- 
ner  and  later  adopted  by  many  pediatricians.  We  shall  speak 
of  it  again. 

In  conclusion,  what  points  of  this  lengthy  discourse  are  going 
to  be  of  value  to  you  in  the  feeding  and  treatment  of  nutritional 
disease?  Remember,  first  and  foremost,  the  great  differences 
in  putrefaction  and  fermentation;  that  any  protem  remaming 
unabsorbed  leads  to  putrefaction  and  alkaU  formation,  with 
resulting  hard,  constipated  stools;  that  any  carbohydrate  re- 
maining unabsorbed  in  the  intestinal  tract  leads  to  fermentation 
and  acid  formation,  with  diarrhea  and  watery  stools.  Remember, 
fermentation  of  the  carbohydrate  is  greatly  increased  by  the 
whey  elements  of  cow's  milk  and  by  any  diseased  or  weakened 
condition  of  the  child's  intestine.  Normally,  due  to  their  gradual 
digestion,  starch  and  dextrin  ferment  less  readily  than  simple 
sugars.  Remember,  in  a  general  way,  the  stool  content,  and 
that  fat  in  the  form  of  alkaline  soaps  gives  structure  to  the  stool. 
This  is  the  fat  in  combination  chiefly  with  calcium  and  mag- 
nesium. Remember  that  in  the  stools  normally  no  carbohydrate 
is  present,  and  that  when  milk  is  boiled,  no  undigested  protein 
is  found,  thus  disproving  in  a  rather  general  way  the  previously 
held  idea  of  indigestibihty  of  cow's  milk  casein.  Remember 
the  functions  of  the  different  elements  of  the  food.  Protein 
and  salts  make  up  the  tissues  of  the  body.  Remember  what  we 
said  about  carbohydrate,  and  that  carbohydrate  and  salts  seem 
to  be  important  factors  in  pulhng  water  into  and  out  of  the 
baby's  tissues. 


LECTURE  m 

MODERN  CONCEPTION  OF  DISTURBANCES  OF 
NUTRITION 

Gentlemen,  in  the  last  two  lectures  we  concerned  ourselves 
with  the  subject  of  milk  and  with  the  subject  of  milk  and  the 
baby.  Today  let  us  start  the  most  fascinating  of  all  studies, 
the  study  of  the  baby.  We  wish  to  consider  that  great,  bewilder- 
ing group  of  ailing,  non-thriving,  sick  children,  some  with  diar- 
rhea, some  with  constipation,  described  by  the  various  terms 
atrophy,  marasmus,  malnutrition,  inanition,  indigestion,  gastro- 
enteritis, ileocoUtis,  cholera  infantum,  and  dysentery.  You 
probably  are  conversant  with  the  methods  and  teachings  of 
the  eastern  schools.  My  purpose  is  now  to  give  you  the  view- 
point of  the  middle  West.  In  a  general  way  we  follow  the 
European  ideas.  Wishing  information  from  the  very  source, 
our  younger  men  have  sought  foreign  clinics,  and  it  is  informa- 
tion thus  obtained  which  I  wish  to  convey  to  you.  After  you 
have  thoroughly  mastered  our  methods  you  will  be  in  a  posi- 
tion to  survey  comprehensively  the  entire  field  and  to  make  an 
intelligent  decision  for  yourselves. 

A  little  review  of  history  will  be  of  great  aid  in  understanding 
the  modern  developments.  Let  us  return  for  a  moment  to  the 
autopsy  room  in  Vienna  some  twenty  or  thirty  years  ago. 
Vienna,  as  you  know,  is  almost  the  home  of  pathology.  Post- 
mortem examination  is  conducted  with  the  same  rigid  care  and 
exactness  as  is  clinical  investigation.  Every  patient  who  dies 
in  the  Vienna  hospital  must  come  to  postmortem.  It  is  natural 
that  with  such  facilities,  the  whole  Vienna  teaching  should 
follow  pathological-anatomical  lines.  Even  the  clinicians  made 
pathology  the  foundation  of  their  diagnoses,  and  it  was  only 
logical  to  attempt  to  divide  this  great  group  of  sick  children 
into  classes  according  to  pathological  findings.  In  Vienna  one 
might  say  the  conception  was  as  follows: 

178 


MODERN   CONCEPTION   OF   DISTURBANCES   OF   NUTRITION       179 

The  well  baby  was  in  a  The  sick  baby  might  be 

group  exclusively  by  him-        affected  with— 
self. 

a.  Dyspepsia. 

b.  Entero-catarrh. 

c.  Cholera  infantum, 

d.  Follicular  enteritis,  etc. 

This  was  the  consensus  of  opinion  of  the  great  Viennese  pedia- 
tricians and  pathologists.  To  them  a  well  baby  was  a  child  to 
be  neglected,  not  to  be  considered  by  medical  men.  The  well 
baby  might  play  in  his  nursery;  be  of  no  interest  until  he  as- 
sumed one  of  the  types  of  disease.  These  types  were  described 
as  local  pathological-anatomical  changes  in  the  gastro-intestinal 
tract.  In  other  words,  if  the  baby  vomited,  he  had  gastritis. 
If  he  vomited  and  had  a  sUght  diarrhea,  he  had  a  gastro-enteritis. 
If  he  had  a  diarrhea  with  bloody  stools,  he  had  ileocoUtis  or 
possibly  folUcillar  enteritis. 

You  see,  then,  that  such  a  viewpoint  made  a  sharp  distinction 
between  the  well  baby  and  the  sick  baby.  The  well  baby  was 
uninteresting,  but  the  sick  baby,  by  showing  local  changes  in 
his  gastro-intestinal  tract,  became  very  attractive  and  an  object 
of  much  study.  When  it  came  to  putting  this  classification 
into  clinical  practice,  however,  great  difficulties  arose,  and 
when  these  clinical  pathological  diagnoses  had  been  established, 
autopsy  frequently  failed  to  confirm  them.  Clinical  pictures 
often  changed.  What  one  day  was  diagnosed  entero-catarrh 
became  the  following  day  cholera  infantum.  Not  even  in  sharp 
pictures,  such  as  follicular  enteritis,  could  the  ulcerated  intes- 
tine always  be  demonstrated.  And  in  many  cases  showing  the 
severest  clinical  symptomatology,  as,  for  instance,  cholera  in- 
fantum, postmortem  examination  not  rarely  showed  absolutely 
no  change  in  the  digestive  tract  other  than  perhaps  a  slight 
reddening  of  the  mucous  membrane. 

Slowly  the  pathologists  became  discouraged.  Gradually 
they  lost  their  interest  in  seeking  pathological  foundations,  and 
now,  if  one  goes  to  Vienna  and  stands  in  the  great  autopsy  room, 
the  lack  of  interest  shown  in  the  postmortem  examination  of 
infants  is  impressive.  While  great  groups  of  men  crowd  around 
the  tables  seeking  knowledge  from  the  carefully,  accurately  con- 


180  INFANT  FEEDING   (CHICAGO  METHODS) 

ducted  autopsies  of  adults,  dead  infants  are  often  absolutely 
neglected — not  even  examined.  When  one  asks  the  busy  pro- 
fessor why  such  and  such  a  child  is  not  autopsied,  the  answer 
is  a  shrug  of  the  shoulders  and  "  What's  the  use?  We  never  find 
anything."  This  mute  evidence  from  the  anatomy  room  of 
Vienna  speaks  for  the  utter  failure  of  pathology  to  provide  a 
classification  for  these  disturbances. 

The  next  attempt  was  made  by  the  great  Vienna  pediatrician, 
Escherich.  Not  satisfied  with  pathology,  he  and  his  assistants 
sought  etiological  factors  in  pathogenic  bacteria.  Numerous  and 
valuable  researches  were  conducted,  but  in  vain,  for  no  specific 
microorganisms  seemed  to  produce  these  chnical  entities.  When 
I  say  "He  failed,"  gentlemen,  I  do  not  mean  that  he  failed. 
His  service  was  of  tremendous  importance,  because  negative 
evidence  is  as  valuable  as  positive,  and  we  could  proceed  only 
after  having  learned  that  our  classification  could  not  be  founded 
upon  bacteriology. 

The  next  step  was  taken  by  that  almost  romantic  figure  in 
pediatrics,  Adalbert  Czerny,  the  brilliant  Austrian  clinician 
who  occupied  the  chair  of  children's  diseases  at  Breslau.  His 
great  mentality,  aided  by  keen  chnical  observation,  has  given 
the  pediatricians  of  the  world  the  most  novel  and  most  useful 
conception  we  have  yet  received.  We  must  forever  be  indebted 
to  him  for  introducing  the  new  term,  "disturbance  of  nutrition." 
In  employing  this  term  we  already  have  a  premonition  of 
changes  that  will  affect  our  therapy.  This  term  implies  that 
the  child  as  a  whole  is  affected,  rather  than  exclusively  his  gas- 
tro-intestinal  tract.  Even  though  the  trouble  originates  in  the 
digestive  organs,  even  though  symptoms  may  entirely  be  those 
from  stomach  and  intestine,  still  every  organ  in  the  body  is  af- 
fected. What  a  thought  is  this,  gentlemen,  to  guide  us  in  our 
therapy!  If  the  child  as  a  whole  is  affected,  we  must  admit  that 
changes  take  place  in  his  bones,  in  his  muscles,  in  his  skin,  in  his 
complete  organism;  and  already  our  keen  interest  in  the  stool 
must  wane.  The  stool  becomes  no  longer  our  sole  guide  to 
therapy  but  merely  one  of  many  symptoms. 

Czerny  was  one  of  the  first  to  doubt  the  indigestibihty  of 
cow's-milk  casein.     With  the  doctrine,   "Protein  can  do  no 


MODERN   CONCEPTION   OF   DISTURBANCES    OF   NUTRITION       181 

harm,"  the  very  antithesis  of  former  teaching,  his  skeptical  brain 
cast  the  pediatrics  world  into  furor 

Realizing  the  failures  of  pathology  and  bacteriology  as  aids  in 
classification,  he  directed  his  studies  from  the  viewpoint  of 
etiology  and  gave  us  the  famous  Czerny  classification.  The 
grouping  of  "disturbances  of  nutrition"  is  according  to  etiology. 

1.  Disturbances  on  the  basis  of  infection.  These  may  be  of 
two  types: 

(a)  Direct  bacterial  infection  of  the  child. 
(6)  Milk  or  food  spoiled  by  bacterial  action. 

2.  Disturbances  on  the  basis  of  constitution. 

3.  Disturbances  on  the  basis  of  food.  Of  these,  Czerny  de- 
scribed two  clean-cut  clinical  entities: 

(a)  The  condition  which  he  called  "milk  injury,"  namely,  a 
rather  pasty,  flabby  child,  not  very  sick,  but  not  thriving,  and 
very  constipated.  Czerny  thought  the  etiology  of  this  condi- 
tion to  be  high  fat  feeding;  and  so,  though  he  gave  the  name 
"milk  injury,"  he  really  meant  "fat  injury." 

(6)  The  condition  he  called  "starch  injury,"  a  Httle  ema- 
ciated, weak,  undernourished  baby,  who  has  received  an  exclu- 
sively one-sided  starch  diet. 

Czerny's  immeasurable  contribution  in  this  classification  was 
the  introduction  of  food  factors,  in  the  causation  of  a  clinical 
picture.  For  the  very  first  time  we  hear  and  think  of  a  sharply 
defined,  clearly  described  disease  being  due  to  nothing  other 
than  the  food  we  offer  the  baby — perfectly  good  wholesome  food, 
but  mixed  in  improper  proportions.  What  a  tremendous  differ- 
ence in  our  viewpoint  results  as  regards  our  conception  of  the 
well  baby!  What  Czerny  has  done  is  to  impress  upon  us  that 
the  well  baby  is  not  necessarily  well,  but  by  a  little  one-sided 
feeding  can  be  brought  right  over  into  the  group  which  we  had 
reserved  entirely  for  the  sick.     Like  this  (Fig.  6) : 

»ell  Baby Sick  Bal>y 

From  Confitltution, 

From  Infection* 

'Fron  Food, 
Fig.  6. 


182  INFANT   FEEDING    (CHICAGO   METHODS) 

In  this  study  Czerny  limited  to  two  the  clinical  types  which 
improper  feeding  could  produce,  namely:  the  pasty,  consti- 
pated child  resulted  from  fat,  and  the  emaciated,  undernour- 
ished one  from  exclusive  starch.  The  diarrheal  diseases  he  be- 
lieved due  either  to  definite  intestinal  infection  or  to  milk  spoiled 
by  bacterial  action. 

Contemporaneous  with  Czerny,  Finkelstein  in  Berlin  was 
making  remarkable  clinical  studies.  Perfectly  independently 
these  two  men  worked,  Czerny  seeking  the  causes  of  disease 
and  Finkelstein  describing  clinical  pictures.  Not  by  theorizing, 
not  by  hypothesis,  but  by  careful  observation  at  the  bedside, 
sitting  with  his  Httle  patients  by  the  hour,  studying  them  with 
the  care  of  a  scientist  in  his  laboratory,  did  Finkelstein  arrive 
at  conclusions  which  threw  the  already  perturbed  scientific 
world  into  chaos.  The  opportunities  for  clinical  investigation 
in  Berhn  are  enormous.  Many  great  institutions  care  for  the 
large  number  of  illegitimate  children  that  exist  in  that  city. 
Finkelstein's  alone  has  over  300  beds  for  infants  under  two  j'^ears 
of  age.  Studying  and  observing  such  infants  are,  of  course, 
much  simpler  than  in  private  practice,  or  even  in  ordinary 
hospital  work.  Many  great  men  are  in  charge  of  these  institu- 
tions, many  have  had  the  same  opportunity  as  Finkelstein; 
but  none  had  the  great  chnical  insight  and  judgment  to  ac- 
comphsh  what  he  has. 

His  studies  were  of  a  purely  clinical  nature.  He  saw  that 
some  children  had  diarrheas;  some  had  constipation;  some  had 
fever,  some  subnormal  temperature.  In  some  the  pulse  was 
markedly  accelerated;  in  others  it  was  slow,  feeble,  and  ir- 
regular. In  some  respiration  was  increased,  rapid,  and 
deep;  in  others  it  was  slow  and  weak.  In  some  the  urine 
was  full  of  sugar,  albumin,  and  casts;  in  others  it  was  perfectly 
normal. 

Varying  from  the  velvety  pink  of  the  normal  to  the  inelastic, 
flabby,  mi^<i-colored  tint  of  the  child  in  disease,  the  skin  seemed 
subject  to  infinite  variations  and  change.  So  was  it  with  the 
muscles,  some  being  normal,  some  rigid,  some  flabby. 

In  one  type  of  child  with  evidence  of  great  cerebral  involve- 
ment consciousness  was  markedly  disturbed,  and  in  another  the 
sensorium  was  perfectly  free. 


MODERN   CONCEPTION   OF  DISTURBANCES   OF  NUTRITION      183 

In  these  clinical  studies  Finkelstein  brought  out  one  fact, 
the  importance  of  which  long  had  been  overlooked;  namely, 
the  child's  weight  curve  (Fig.  7).  To  make  a  weight  curve  one 
must  weigh  the  baby  every  few  days,  preferably  every  day, 
and  plot  out  a  curve  upon  a  tabulated  sheet,  as  one  does  for 
temperature,  pulse,  and  respiration,  or  just  as  simply  conceive 
it  in  the  mind.  These  studies  showed  that  weight  curves 
were  diagnostic  of  definite  clinical  entities.  He  called  atten- 
tion to  the  curve  of  the  healthy  breast-fed  baby,  gaining 
steadily,  the  gain  each  day  being  like  the  one  previous.     He 


Days 

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Fig.  7. 


reminded  us  of  the  zigzag  curve  of  the  bottle  baby,  and  sug- 
gested that  this  irregularity  was  due  to  the  irregular  retention 
and  excretion  of  salts.  You  remember  that  cow's  milk  is  richer 
than  breast  milk  in  mineral  matter,  and  that  being  concerned  in 
the  retention  of  water  in  the  baby's  body,  salts  markedly  in- 
fluence the  weight. 


184 


INFANT   FEEDING    (CHICAGO   METHODS) 


He  showed  a  curve  characterized  by  cessation  of  gain.  He 
showed  a  curve  characterized  by  gradual  loss.  He  showed  a  curve 
characterized  by  acute  severe  loss.  And,  lastly,  he  showed 
the  curve  of  a  chronically  sick  baby,  sick  for  weeks  or  months. 

These  four  curves  (Fig.  8)  are  typical  and  practically  diag- 
nostic of  four  distinct  types  of  cases,  each  one  of  which  might 
be  produced  through  improper  feeding.  His  entire  classifica- 
tion is  a  comprehensive  one,  but  for  the  present  let's  confine 


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Fig.  8. 

ourselves  to  this  group  which  Czemy  first  introduced  and 
Finkelstein  so  greatly  enlarged,  namely,  "Disturbances  of  Nu- 
trition" on  the  basis  of  food.  Why  Finkelstein  was  not  satis- 
fied with  etiology  as  a  means  of  classification  he  explains  in  his 
modest  way  by  saying:  "We  are  still  in  such  a  maze  that  it 
might  perhaps  be  wiser,  as  a  guide  to  us  in  further  study,  for  the 
present  to  content  outselves  with  clinical  pictures.  The  truth 
is  always  to  be  found  at  the  bedside."  His  classification  of  food 
disturbances  is  as  follows: 


MODERN   CONCEPTION    OF   DISTURBANCES   OF   NUTRITION    185 

1.  Failure  to  Gain. — Infants  who,  though  not  very  sick,  are 
not  thriving  nor  gaining  as  they  should.  They  usually  have 
constipated,  soapy  stools  and  are  subject  to  infections. 

2.  Dyspepsia. — Here  the  picture  is  that  of  a  mild  diarrhea. 
The  child  is  not  very  sick,  but  is  a  little  peevish  and  irritable — 
the  type  which  you  gentlemen  would  call  a  mild  gastro-enteritis 
or  a  mild  summer  complaint. 

3.  Intoxication.— This  is  a  very  sick  child.  Diarrhea  is 
marked ;  loss  of  weight,  rapid  and  severe.  Consciousness  is  dis- 
turbed, and  the  temperature  high.  It  is  much  the  same  picture 
that  you  gentlemen,  I  presume,  would  call  a  very  severe  gastro- 
enteritis or  a  cholera  infantum. 

4.  Decomposition. — In  this  condition  the  child  has  been 
chronically  ill  with  feeding  difficulties.  Nothing  has  agreed  with 
him  for  weeks.  He  shows  the  great  emaciation  and  under- 
nourishment of  which  the  terms  atrophy,  malnutrition,  and 
marasmus  are  descriptive. 

Not  only  are  we  indebted  to  Finkelstein  for  this  beautiful  new 
clinical  classification,  but  we  owe  him  everlasting  gratitude  for 
introducing  into  the  study  of  disease  a  new  food  factor.  Czemy 
introduced  fat,  and  thought  overfeeding  in  fat  brought  on  milk 
injury,  with  its  associated  constipation.  Finkelstein,  with  this 
same  viewpoint,  studied  sugar,  and  it  was  his  idea  that  over- 
feeding in  sugar  produced  diarrhea.  What  a  startUng  new  con- 
ception this  was!  When  he  described  to  us  the  severe  picture 
of  intoxication,  which  you  would  call  cholera  infantum,  and  laid 
the  cause  of  this  hitherto  deadly,  often  mysterious  disease, 
simply  to  excess  of  sugar  in  the  feeding,  the  interested  profession 
was  stunned,  amazed,  and  unbelieving.  In  rapid  succession, 
from  all  parts  of  the  world,  seeking  to  confirm  or  to  disprove  this 
view,  innumerable  new  investigations  and  experiments  were 
started,  and  although  many  of  the  original  theories  have  been 
modified,  the  infinite  value  of  this  fundamental  observation 
impresses  us  ever  more  and  more. 

The  third  invaluable  contribution  of  Finkelstein  was  the 
grouping  of  these  four  types  under  the  head  of  "disturbances  of 
nutrition."  Like  Czerny,  when  Finkelstein  studied  diarrheal 
disease  and  noted  the  changed  pulse-rate,  the  changed  respira- 
tion, the  changed  temperature,  the  disturbed  consciousness, 


186  INFANT   FEEDING    (CHICA.GO   METHODS) 

and,  above  all  things,  the  variable  and  impressive  weight  re- 
actions, we  readily  can  imagine  his  reasoning:  "Certainly  this 
disturbance  must  be  one  involving  more  than  the  digestive 
canal.  No  matter,  even  though  the  origin  be  purely  gastro- 
intestinal, if  every  function  of  the  body  is  involved  and  affected, 
we  must  think  of  the  child  as  one  in  whom  the  entire  nutrition 
is  changed,  and  certainly  such  change  must  have  great  influence 
upon  our  treatment.  Under  no  circumstance  must  we  think  of 
the  gastro-intestinal  tract  alone."  This  viewpoint  has  been 
inestimable  in  directing  our  therapy  away  from  the  child's  stool 
to  that  of  the  child's  body.  We  beheve  that  the  stools  are 
valuable  symptoms  of  disturbance  of  the  gastro-intestinal  tract ; 
but  viewing  our  little  patients  from  the  broad  conception  of 
"disturbance  of  nutrition,"  after  having  noted  the  symptom  of 
the  stool,  we  often  neglect  it  entirely,  considering  it  only  in  its 
relation  to  the  entire  clinical  picture. 

According  to  the  viewpoint  of  Finkelstein,  the  grouping  of 
diarrheal  diseases  as  "disturbances  of  nutrition"  must  make 
stool  examination  absolutely  incidental  to  the  examination  of 
the  entire  baby.  The  sjonptom  of  the  stool  sinks  into  insig- 
nificance beside  the  symptom  of  the  baby  as  a  whole.  The  one 
symptom  representing  the  baby  is  the  weight.  The  stool  is  a 
symptom  to  be  considered,  it  is  true,  but  not  to  be  followed 
blindly.     The  weight  becomes  our  index  for  treatment.      j 

Finkelstein  did  not  deny  as  a  factor  the  influence  of  constitu- 
tion, which  Czerny  had  suggested,  nor  the  importance  of  in- 
fection; but  he  believed,  first  and  foremost,  that  most  disturb- 
ances were  due  not  so  much  to  constitution,  not  so  much  to 
infection,  as  to  food;  and  when  we  say  food  we  mean  perfectly 
wholesome,  good  fresh  cow's  milk,  given  to  the  child,  however, 
in  improper  dilutions.  Whether  one  follows  Czerny  or  whether 
one  follows  Finkelstein  is  immaterial.  Both  men  have  done  the 
world  a  service  for  which  generations  to  come  must  be  grateful. 
From  the  point  of  view  of  the  clinician  the  Finkelstein  classi- 
fication is  perhaps  more  practical. 

A  crude  illustration  might  make  clearer  the  methods  of  these 
two  men.  Suppose  we  lived  two  hundred  years  ago,  when  dis- 
ease was  considered  due  to  evil  spirits,  to  ^vitchcraft,  and  to 
demons.     Suppose  at  that  time  that  out  of  the  bewildering  mass 


MODERN   CONCEPTION    OF   DISTURBANCES   OF   NUTRITION  187 

of  ailments  some  great  mind  had  become  inspired  with  an  idea 
of  infectious  disease,  and  to  the  eager  world  had  exclaimed: 
"Some  of  these  conditions  are  in  a  distinct  group.  They  are 
'infectious  diseases,'  and  exist  as  three  types: 

"Those  from  pneumococcus. 
Those  from  streptococcus. 
Those  from  meningococcus." 

This  is  what  Czerny  did  some  ten  years  ago  when,  out  of  the 
bewildering  mass  of  ailing  infants,  he  saw  "disturbances  of 
nutrition"  and  said  they  could  be  divided  into  three  groups: 

Those  due  to  constitution. 
Those  due  to  infection. 
Those  due  to  food. 

Finkelstein,  on  the  other  hand,  had  he  lived  two  hundred  years 
ago,  when  the  above  hypothetical  individual  had  discovered 
"infectious  disease,"  would  have  said:  "I  certainly  agree  that 
there  is  a  great  group  of  diseases  due  to  infection.  We  know  so 
httle  about  them,  however,  that  I  think  we  had  better  stick  to 
the  clinical  pictures  and  later  we  can  worry  about  the  causes." 
He  then  might  have  described,  for  example : 

Pneumonia. 
Meningitis. 
Septicemia. 
Rheumatism. 

He  would  have  agreed  that  these  pictures  might  each  one  be  due 
to  the  pneumococcus,  streptococcus,  or  meningococcus,  but 
wouldn't  have  committed  himself  definitely.  In  the  same  way 
the  Finkelstein  classification  recognizes  "disturbances  of  nu- 
trition" and  shows  four  cUnical  pictures: 

1.  Failure  to  gain. 

2.  Dyspepsia. 

3.  Intoxication. 

4.  Decomposition. 

He  accepts  the  etiological  factors  offered  by  Czerny — con- 
stitution, infection,  and  food;  but  the  advantage  of  his  view- 
point is  that  he  leaves  the  field  more  easily  opened  for  further 
additions  as  to  etiology. 


188  INFANT   FEEDING    (CHICAGO   METHODS) 

Either  classification  is  correct.  It  makes  no  difference  which 
you  follow;  but  from  the  clinical  aspect  the  Finkelstein  idea  is 
perhaps  more  practical,  for  it  resembles  our  clinical  classification 
of  infectious  disease.  As  clinicians,  what  we  seek  first  is  a 
clinical  picture.  When  we  go  to  the  bedside  we  do  not  ask 
ourselves,  "Is  this  a  disturbance  due  to  pneumococcus  or  strep- 
tococcus or  meningococcus?"  but  we  do  ask,  "Is  this  a  pneu- 
monia or  a  septicemia  or  a  meningitis?"  And  having  estab- 
lished that,  then  we  seek  the  etiological  factors.  The  beauty 
about  a  clinical  classification  is  that  it  is  true.  Theories  may 
be  altered,  ideas  changed,  new  explanations  advanced,  but  "in 
the  chnic  lies  the  truth." 

Having  clean-cut  clinical  pictures,  we  are  in  a  better  position 
to  seek  causative  factors.  Just  as  in  septicemia  we  have  learned 
that  much  the  same  picture  may  be  due  to  pneumococcus,  strep- 
tococcus, or  influenza,  so  can  we  amphfy  these  clinical  types  of 
I'inkelstein.  This  classification  I,  myself,  do  not  believe  to  be 
the  last  word.  I  doubt  if  it  will  stay  with  us  permanently;  but 
it  will  be  of  invaluable  help  in  further  study. 

Having  recognized  these  four  clinical  tjT)es,  Finkelstein  him- 
self began  to  seek  causes — to  fill  in  the  subheadings.  Stimu- 
lated by  Czerny's  description  of  fat  injury  and  by  his  own  dis- 
covery of  the  diarrheal  effect  of  sugar,  he  attempted  to  place 
all  four  of  these  clinical  pictures  upon  a  food  basis.  In  a  crude 
way  one  might  say  his  first  idea  was  as  follows  (Fig.  9) : 


Failure  To  Qaln 

I 


Intoxication  ■*=—  Decomposition* 

Fig.  9. 

Failure  to  gain  was  due  either  to  insufficient  food  or  to  over- 
feeding with  fat.  The  latter  was  the  very  same  condition  that 
Czerny  described  as  "milk  injury,"  Finkelstein's  term,  how- 
ever, for  reasons  which  we  will  discuss  later,  was  "disturbed 
balance."  Continuance  of  the  overfeeding  with  fat  led  to  the 
decomposition  stage.     Overfeeding  with  sugar  led  to  the  stage 


MODERN   CONCEPTION   OF  DISTURBANCES   OF   NUTRITION  189 

of  dyspepsia.  If  the  overfeeding  with  sugar  were  continued  in 
the  stage  of  dyspepsia,  intoxication  resulted.  If  the  mistake 
was  overfeeding  with  fat  in  the  stage  of  dyspepsia,  decomposi- 
tion resulted. 

This  viewpoint  has  been  greatly  modified.  The  hundreds  of 
studies  all  over  the  world,  stimulated  by  the  novel  idea,  have 
brought  great  light.  The  all-important  result  of  this  first  idea 
of  Finkelstein  was  to  bring  the  well  baby  and  the  sick  baby 
closer  together.  The  well  baby  can  now  no  longer  be  secluded 
in  his  nurserj^,  independent  of  all  interest,  only  to  come  to  notice 
when  he  shows  abnormal  symptoms.  The  well  baby  may  at 
any  moment,  due  to  a  httle  improper  feeding,  enter  the  group  of 
sick  babies.  Let  me  impress  upon  you  gentlemen,  that  Finkel- 
stein did  not  deny  infections  as  a  factor,  did  not  deny  constitu- 
tion as  a  factor;  but  of  all  things  he  did  impress  upon  us  the 
very,  very  great  importance  of  food,  and  he  attempted  to  show 
that  many  of  the  clinical  pictures  of  even  the  very  worst  diar- 
rhea were  due,  not  to  external  influence,  but  to  the  milk  mixtures 
which  we  ourselves  were  feeding  the  baby.  This,  of  course,  has 
been  of  unspeakable  importance  in  guiding  our  therapy  and 
stimulating  us  to  deeper  thought. 

Finkelstein's  idea  as  to  the  importance  of  food  has  under- 
gone, during  recent  years,  considerable  revision.  Continued 
studies  from  all  parts  of  the  world  have  introduced  new  and 
reemphasized  old  factors.  Now  we  recognize  many  influences 
other  than  food.  Finkelstein's  latest  classification  is  as  follows: 
A.  Food. 

I.  Perfectly  good,  wholesome  food,  i.e.,  pure,  fresh  cow's  milk. 
(a)  Overfeeding.     This  may  be  of  two  types: 

1.  Too  great  quantity. 

2.  A  preponderance  of  one  of  the  elements  of  the 

milk,  too  much  fat  or  too  much  sugar — the  group 
which  Czemy  and  Finkelstein  called  so  strik- 
ingly to  our  attention. 
(6)  Hunger.    This  may  be : 

1.  Insufficient  total  quantity. 

2.  Insufficiency  of  one  or  more  elements  of  the  milk, 

as  protein  and  salt  deficiency  in  prolonged 
use  of  barley  water  and  gruel. 


190  INFANT  FEEDING    (CHICAGO  METHODS) 

II.  Spoiled  milk  and  food.  The  factor  to  which  Czemy 
ascribed  diarrheal  disease,  the  one  which  Finkel- 
stein  considered  unimportant  as  compared  to 
sugar  in  the  diarrhea  of  nurslings.  Both  observers 
admit  the  importance  of  spoiled  food  in  diarrheas 
of  older  children. 

B.  Underlying  Weak  Constitution,  or  any  factor  weakening 

the  constitution,  such  as  heat,  is  an  influence  of 
no  small  importance. 

C.  Milder  Infections,  such  as  coughs  and  colds,  bronchitis, 

and  cystitis,  are  important  predisposing  agencies. 

D.  Nursing  injuries  may  be  of  two  types: 

I.  The  failure  of  the  individual  nurse  in  allowing  her  charge 
to  suffer  from  improper  care,  from  uncleanliness, 
from  overclothing,  overheating,  or  exposure. 
II.  A  weakness  inherent  to  our  hospitals  is  the  infant  ward. 
Here  one  nurse,  no  matter  how  efficient,  is  in  charge 
of  several  babies.  She  cannot  give  each  child 
the  necessary  individual  care.  She  cannot  take 
proper  interest  in  the  preparation  of  the  bottles, 
nor  give  personal  attention  during  feedings.  The 
children,  suffering  from  lack  of  exercise,  resemble 
plants  rather  than  animals,  and  each  day  approach 
more  closely  the  danger  of  a  disturbance  of  nu- 
trition. 

DIAGNOSIS 

How  do  we  diagnose  a  nutritional  disturbance?  Besides  care- 
ful physical  examination,  we  have  two  valuable  aids: 

1.  A  careful  history.  Information  of  frequent  digestive  dis- 
turbances, of  frequent  infections,  improper  care,  a  weak  consti- 
tution, or  backward  development,  would  lead  us  to  think 
strongly  of  nutritional  disturbance  as  a  factor  in  the  present 
complaint. 

2.  Above  all  things,  gentlemen,  never  neglect,  and  learn  to 
know,  the  reactions  to  food  and  to  hunger. 

(a)  In  one  child  Avith  severe  diarrhea  the  addition  of  a  full 
bottle  of  food  may  be  fatal,  the  child  djdng,  wdth  a  rapid  loss 
of  weight  and  with  the  severest  symptoms  of  intoxication.     In 


MODERN   CONCEPTION   OF   DISTURBANCES   OF   NUTRITION  191 

this  same  child,  the  complete  withdraw^al  of  food  for  twenty-four 
hours  seems  to  effect  a  rapid,  striking  improvement.  It  was,  in 
a  way,  this  so-called  paradoxical  reaction  that  first  led  Finkel- 
stein  to  the  careful  study  of  food  in  these  diarrheal  conditions. 
Addition  of  food  kills :  withdrawal  of  food  saves.  What  better 
clinical  evidence  can  we  demand  of  the  vital  importance  of  food? 

(6)  In  some  children  complete  withdrawal  of  food  for  twenty- 
four  hours  leads,  with  all  symptoms  of  collapse,  to  rapid  loss  of 
manj'  ounces  of  weight  and  death. 

Of  these  clinical  pictures,  of  these  weight  curves,  of  these  food 
reactions,  we  shall  hear  more. 

To  conclude,  we  have  learned  this  morning  that  in  the  great 
group  of  non-thriving  children,  the  children  with  diarrhea,  the 
children  with  constipation,  pathological,  examination  of  the 
intestinal  tract  as  a  means  of  classification  is  of  little  aid.  We 
have  learned  that  the  science  of  bacteriology  helps  us  but  little. 
Gzerny,  with  the  conception  of  "disturbance  of  nutrition," 
takes  our  attention  away  from  the  intestinal  tract,  makes  us 
think  of  the  baby  as  a  whole,  and  Czerny  does  us  an  infinite 
service  by  doubting  the  danger  of  protein  and  first  calUng  to 
our  attention  the  importance  of  food  (of  fat)  in  the  production 
of  the  clinical  picture  of  non-thriving,  constipated  children. 
Finkelstein,  in  a  way  following  the  footsteps  of  Czerny,  arriving 
at  these  conclusions  through  careful  chnical  observation,  im- 
presses us  with  the  importance  of  all  foods  in  causing  these  dis- 
turbances, agreeing  with  Czerny  in  some  respects  as  to  the 
effects  of  fat,  and  doing  us  immeasurable  good  in  calling  to  our 
attention  the  diarrheal  effects  of  sugar.  Laying  lesser  stress 
upon  constitution  and  infection  in  the  production  of  these  dis- 
eases, he  believes  disturbances  of  nutrition  almost  exclusively 
to  be  due  to  food — perfectly  good,  wholesome  milk,  but  given  in 
improper  amounts  and  diluted  in  improper  proportions.  We 
can  never  be  sufficiently  grateful  to  him  for  placing  diarrheal 
diseases  also  under  the  term  "disturbance  of  nutrition." 

This  magnificent  conception  is  of  inestimable  value  to  us  in  the 
treatment  of  our  children.  From  this  viewpoint  the  stool  be- 
comes a  symptom,  the  baby  as  a  whole  becomes  the  important 
consideration.  The  stool  becomes  absolutely  subservient  to  the 
whole  clinical  picture.     Just  think  what  this  means!     This 


192  INFANT  FEEDING    (CHICAGO  METHODS) 

means  we  must  never  devote  ourselves  to  the  intestine  alone,  but 
only  the  intestine  in  relation  to  the  whole  body.  In  our  deeper 
interest  in  the  child's  body  we  may  be  forced  to  do  what  seems 
to  be  worst  for  the  intestinal  tract.  This  viewpoint  impresses 
upon  us  finally,  irrevocably,  the  tremendous  importance  of  the 
weight  curve.  The  weight  curve  expresses  the  condition  of  the 
baby  as  a  whole;  the  stool,  only  that  of  intestinal  tract. 

With  this  conception  of  the  fundamental  importance  of  food, 
the  well  baby  becomes  a  sick  baby.  The  well  baby  may  assume 
any  clinical  picture  by  varying  his  feeding.  Gentlemen,  if  you 
will  remember  this,  if  you  will  only  see  your  well  babies  more 
often,  if  you  only  will  think  of  them  as  sick  babies,  will  treat 
them  with  the  same  care  and  consideration  that  you  would  a 
patient  with  infectious  disease,  I  can  assure  you  that  you  will 
have  little  trouble  with  the  babies,  little  trouble  with  the  moth- 
ers, and  the  feeding  cases  in  your  practice  will  become  a  pleasure 
rather  than  a  burden. 


LECTURE  IV 

FAILURE  TO  GAIN 

Gentlemen,  you  remember  in  our  last  lecture  we  spoke  of  the 
viewpoints  of  the  various  great  pediatricians.  We  told  of  the 
failure  of  the  Vienna  school  to  place  nutritional  disease  upon  a 
definite  pathological-anatomical  basis.  We  spoke  of  the  failure 
of  Escherich  to  find  specific  bacterial  causes.  Don't  misunder- 
stand me,  gentlemen;  the  ideas  failed.  The  men  succeeded. 
Patient,  conscientious  perseverance  cleared  away  the  obstacles 
that  otherwise  would  have  prevented  the  advent  of  newer  con- 
ceptions. You  remember  it  was  Adalbert  Czerny,  the  skeptic, 
the  keen  observer,  the  deep  philosopher,  who  gave  us  newer 
thoughts.  You  remember  he  no  longer  spoke  of  disease  of  the 
gastro-intestinal  tract.  To  him  these  disturbances  were  "dis- 
turbances of  nutrition."  The  baby  no  longer  was  diseased 
solely  in  his  stomach  and  intestines,  but  changes  were  effected 
in  every  sinew  and  fiber  of  the  body.  It  was  Czerny  who,  for 
the  first  time,  cast  doubt  upon  the  orthodox  idea  of  the  in- 
digestibility  of  cow's-milk  casein.  It  was  Czerny  who,  for  the 
first  time,  called  to  our  attention  the  factor  of  food  in  the  pro- 
duction of  definite  chnical  entities.  With  two  clean-cut  chnical 
pictures  he  brought  to  our  notice  fat  and  starch.  Too  much 
fat  was  the  causative  factor  in  non-thriving,  constipated  in- 
fants; too  much  starch  produced  another  clinical  entity.  It 
was  Czerny  who  gave  an  etiological  classification.  You  re- 
member the  classification?  Nutritional  disturbances  were 
those — 

a.  On  the  basis  of  constitution. 

b.  On  the  basis  of  infection;  these  were  the  diarrheal  diseases. 
Two  factors  might  be  concerned: 

(1)  True  infection  of  the  gastro-intestinal  tract  with  germs 
of  specific  diseases,  such  as  dysentery  or  cholera. 
13  193 


194  INFANT   FEEDING    (CHICAGO   METHODS) 

(2)  Poisoning,  resulting  from  the  drinking  of  spoiled  food — 
food  which  had  not  properly  been  cared  for  and  had  become  a 
great  culture-medimn  for  the  common  every-day  organisms. 

c.  Disturbances  due  to  food: 

(1)  Milk  injury. 

(2)  Starch  injury. 

So,  if  we  follow  Czerny,  we  no  longer  speak  of  gastritis,  gastro- 
enteritis, and  cholera  infantum ;  but  rather  of  a  disturbance  due 
to  constitution,  due  to  infection,  or  due  to  food. 

In  a  and  h  he  gave  us  etiological  factors;  in  c  he  gave  us  an 
etiological  factor  with  two  beautifully  described  clinical  pictures. 

You  remember  while  this  epoch-making  work  was  being 
evolved,  Finkelstein,  in  Berlin,  was  making  great  studies  from 
a  purely  cUnical  viewpoint. 

In  today's  lecture  I  wish  to  discuss  with  you  Czerny's  ''milk 
injury"  and  show  how  this  has  been  modified  by  clinical  obser- 
vation. 

Czerny's  description  roughly  is  as  follows:  A  mother  brings 
her  infant,  complaining  that  he  is  not  thriving  and  that  he  is 
very  constipated;  she  doesn't  regard  him  as  being  sick:  just 
wants  a  little  advice.  You,  doubtless,  have  seen  many  such 
cases.  Upon  examination  you  find  a  rather  pasty,  not  badly 
nourished,  somewhat  anemic-looking  child.  He  is  a  little 
flabby.  You  think  of  a  beginning  rickets;  you  place  him  upon 
the  table  and  he  flops  over,  showing  a  somewhat  flaccid  mus- 
culature. His  weight  is  slightly  below  normal.  Upon  ques- 
tioning the  mother  you  learn  that  he  is  not  gaining  as  he  used 
to;  that  he  is  a  httle  peevish  and  fretful;  he  is  subject  to  mild 
infections;  and,  above  everything  else,  the  mother  dwells  upon 
the  constipated,  dry,  crumbly,  soap-like  stools,  which  charac- 
teristically do  not  adhere  to  the  diaper,  but  easily  can  be  brushed 
away.     To  the  mother  the  chief  trouble  is  constipation. 

You  think  the  child  is  undernourished;  you  increase  his  diet; 
but  he  doesn't  gain.  Possibly  he  becomes  more  peevish  and 
irritable,  and  the  constipated  stools  more  persistent. 

In  seeking  the  cause  of  this  condition,  Czerny  focused  his 
attention  sharply  upon  these  abnormal  bowel  movements,  and 
here  he  made  a  great  discovery.  You  remember  in  our  second 
lecture  we  spoke  of  the  way  in  which  fat  normally  leaves  the 


FAILURE   TO   GAIN  195 

intestine;  that  a  certain  amount  of  it — a  rather  small  percent — 
combines  with  alkalis,  such  as  calcium  and  magnesium,  and 
leaves  in  the  form  of  soap.  To  Czerny's  great  interest,  these 
stools  contained  a  much  greater  percentage  of  soap  than  stools 
of  normal  babies.  If  the  soap  in  a  normal  baby  was  perhaps 
20  percent  of  the  fat  of  the  stool,  in  these  babies  it  might  be  50 
percent.  Czerny's  reasoning  was  clear  and  simple.  If  a  soap 
consists  normally  of  fat  combined  with  calcium  or  magnesium ; 
if  the  stools  of  these  children  contain  an  increased  amount  of 
soap,  then  from  these  children  there  must  be  an  excessive  ex- 
cretion of  mineral  matter,  of  calcium  and  magnesium,  and  the 
general  symptoms  might  be  explained  as  a  disturbance  of  nu- 
trition in  which  loss  of  mineral  matter  plays  a  prominent  part. 
If  the  mineral  matter  combines  with  fat  to  form  soaps,  then  by 
reducing  the  fat  in  the  diet  we  should  decrease  soap  formation 
and  thus  lessen  mineral  loss;  by  increasing  fat  in  the  diet,  we 
should  enhance  soap  formation  and  increase  mineral  loss.  True 
enough,  Czerny's  assistants,  by  offering  these  children  increased 
quantities  of  fat,  were  able  to  increase  soap  formation  and  cause 
greater  mineral  excretion.  The  solution  to  the  question  was 
now  simple.  All  that  was  necessary  was  to  diminish  the  amount 
of  fat  in  baby's  bottle,  substitute  some  food  of  equal  caloric 
value,  and  the  child  should  thrive.  To  accomplish  this,  Czerny 
used  a  mixture  known  as  Keller's  Malt  Soup,  which  is  made  as 
follows : 

(a)  To  one-third  of  a  quart  of  milk  add  1  ounce  of  ordinary 
flour. 

(6)  In  another  mixture,  to  two-thirds  of  a  quart  of  water  add 
about  3}4  ounces  of  malt  soup  extract.  In  this  country  the 
latter  is  put  up  by  Borcherdt  or  the  "Maltine"  concern. 

(c)  Add  the  two  mixtures  together,  boil,  and  you  have  in  the 
resulting  food  an  absolute  cure,  a  perfectly  ideal  treatment. 
The  baby's  constipation  subsides,  the  stools  become  normal,  he 
gains  in  weight,  and  in  every  way  becomes  brighter  and  happier. 

The  following  curve,  taken  roughly  from  the  text  of  Czerny 
and  Keller,  illustrates  Czerny's  idea  (Fig.  10). 

This  child  is  five  months  of  age.  From  birth  he  got  nothing 
but  milk  and  water,  and  was  brought  to  the  clinic  for  typical 
symptoms  of  milk  injury.     He  did  not  sleep  well,  was  restless, 


196 


INFANT   FEEDING    (CHICAGO   METHODS) 


and  showed  the  constipated,  fat-soap  stools.  During  the  first 
half  of  February  he  received  one-third  milk;  during  the  latter 
half,  half  milk,  and  during  March,  full  milk.  Notice  here  a 
slight  rise  in  the  curve,  but  it  is  not  sustained.  In  April  Keller's 
Malt  Soup  resulted  in  the  astonishing  rise.  This  Czerny  at- 
tributed to  reduction  of  fat. 

In  taking  up  this  subject  I  hesitated  somewhat.  Would  it 
be  wiser  to  go  into  detail,  showing  you  the  reasoning  of  these 
observers,  or  to  state  simply  that  "The  symptoms  are  so  and 
so,  the  treatment  so  and  so."  Upon  consideration,  however,  I 
thought  I  should  hke  to  show  you  the  fundamental  "why"  at 


Month 

Feb. 

Uaroh 

April 

Uay 

13  lbs. 
12  lbs. 
11  lbs. 
10  lbs. 

•  • 

^ 

•  • 

• 

X 

WW 

r-l 

V 

-^^ 

7  ^ 

s 

Fig.  10. 


the  basis  of  these  observations,  because  if  you  master  the  under- 
lying principles,  you  wiU  have  the  key  not  only  to  the  treatment 
of  this  particular  condition,  but  also  to  many  of  the  cases  of 
constipation  which  perplex  you  in  your  daily  children's  practice. 
While  these  brilHant  experiments  were  being  conducted  in 
Breslau,  Finkelstein,  in  his  institution  in  Berlin,  was  attacking 
the  problem  by  careful  study  at  the  bedside,  by  accurate  clinical 
observation.  Perfectly  independently  he  studied  a  great  group 
of  children,  many  of  whom  apparently  were  not  very  ill,  all  of 
whom  showed  a  "failure  to  gain."  In  some,  marked  constipa- 
tion was  present ;  in  others,  bowel  movements  were  more  nearly 
normal.    In  these  studies,  Finkelstein  and  the  men  influenced  by 


FAILURE   TO   GAIN  197 

his  teaching,  showed  that  there  were  many  factors  featuring  in 
the  etiology. 

(1)  Some  children  who  showed  the  typical  picture  of  Czerny's 
"milk  injury"  were  getting  insufficient  food;  increase  of  quan- 
tity brought  correction  of  the  intestinal  symptoms  and  speedy 
cure.  This,  strictly  speaking,  does  not  belong  to  the  group  we 
are  discussing.  I  place  it  here,  however,  as  did  Finkelstein,  for 
from  a  clinical  standpoint  in  your  practice  you  frequently  meet 
such  cases.  In  true  "milk  injury,"  as  described  by  Czerny,  in- 
crease in  total  food  volume  does  not  result  in  gain. 

(2)  Some  children  recovering  from  ordinary  infections  showed 
this  very  same  symptomatology.  They  had  been  thriving 
perfectly  until  taken  ill  with  a  cough  or  cold  or  mild  cystitis, 
and  upon  recovery,  with  absolutely  no  change  in  diet,  spon- 
taneously developed  this  disturbance.  Here,  then,  fat  alone  or 
even  the  food,  could  not  be  blamed,  for  the  baby  previously  had 
been  gaining  on  the  very  same  mixture. 

(3)  In  another  group  improper  care  of  the  baby,  whether  in 
the  home  or  in  the  hospital,  in  some  mysterious  way  seemed  to 
predispose.  The  explanation  is  not  as  yet  clear.  You  remem- 
ber we  are  confining  ourselves  to  clinical  observation. 

(4)  A  group  of  children  who  suffer  with  a  weak  constitution, 
congenital  heart  disease,  or  other  hereditary  anomalies  easily 
progress  to  this  condition. 

(5)  Lastly,  the  group  in  clean-cut,  definite  form  in  which  too 
much  milk,  or,  as  Czerny  would  have  it,  too  much  fat,  seemed 
to  be  the  important  factor. 

Gentlemen,  you  already  see  what  tremendous  influence  clinical 
observation  exerted  upon  our  interpretation  of  this  condition. 
Czerny  gave  us  the  wonderful  conception  of  disturbance  of 
nutrition;  then  temporarily  forgot  it  in  his  intense  interest  in 
the  baby's  stool,  and  overlooked  other  factors,  perfectly  inde- 
pendent of  food,  which  might  have  been  concerned.  Finkel- 
stein and  his  students,  in  adhering  to  the  broader  conception,  the 
original  idea  of  Czerny,  regarding  the  stool  purely  and  simply 
as  a  symptom  and  not  as  a  cause,  were  able  to  add  much  to  our 
knowledge. 

Let  us  return  for  a  moment  to  group  (5),  the  cases  in  which  both 
Czerny  and  Finkelstein  noted  a  rather  high  amount  of  fat  in  the 


198  INFANT  FEEDING    (CHICAGO  METHODS) 

diet.  The  many  observations  and  experiments  stimulated  by 
Czemy's  novel  conception  began  to  bear  fruit,  but  as  time  pro- 
gressed these  observations  and  experiments  gradually  began  to 
speak  against  the  primary  influence  of  fat.  First  was  shown 
that  in  some  cases,  in  spite  of  a  high  fat  diet,  in  spite  of  the  fat- 
soap  stool,  there  was  no  total  mineral  loss  to  the  body.  True, 
the  mineral  matter  in  combination  with  fat  was  increased,  but 
the"  mineral  matter  excreted  in  combination  as  salts  was  de- 
creased, and  so  the  sum  total  was  not  above  normal. 

A  second  argument  against  the  primary  importance  of  fat 
was  the  brilUant  metaboUc  work  of  young  Hans  Barth,  whose 
tragic  death  in  the  present  war  has  been  such  a  sad  blow  to 
modern  pediatrics.  He  and  his  coworkers  showed  that  in  many 
cases  the  total  amount  of  mineral  matter  lost  in  the  form  of 
calcium  and  magnesium  was  infinitely  greater  than  could  be  ex- 
plained by  the  soap  formation  in  the  stool. 

And,  lastly,  comes  the  ever-valuable,  unexplainable  clinical 
evidence  that  children  with  well-developed,  perfectly  typical 
milk  or  fat  injury  can  be  cured  in  striking  fashion  by  the 
use  of  breast  milk.  Breast  milk,  as  you  remember,  contains 
the  very  same  amount  of  fat  as  cow's  milk.  This  is  an  unan- 
swerable argument.  If  a  baby  showing  the  picture  of  milk 
injury  on  cow's  milk  feeding  can  be  cured  at  once  by  the  use  of 
breast  milk,  then  fat  exclusively,  by  itself,  can  scarcely  be  the 
sole  factor  in  the  etiology.  We,  blindly  groping  for  explanation, 
must  conclude  that  fat  alone  cannot  be  responsible,  but  fat  plus 
some  invisible  mysterious  element  contained  in  cow's  milk  and 
not  in  breast  milk. 

During  the  furor  accompanying  Czerny's  discovery  and  the 
battles  waged  by  his  supporters  and  his  critics,  Freund  was 
making  brilliant,  almost  conclusive,  experiments  in  his  own  in- 
stitution. He  fed  babies  showing  the  typical  picture  of  milk 
injury  various  foods,  such  as  starch.  This  had  little  effect 
upon  the  stool.  He  fed  them  sugar  of  milk  and  malt  ex- 
tract. Lo  and  behold!  under  the  influence  of  the  latter  articles 
of  diet  the  soaps  disappeared ;  the  fats  were  excreted  in  other 
combinations,  and  constipation  was  cured.  This  observation 
seemed  uncanny — full  of  mystery.  What  could  be  the  under- 
lying principle?  Freund  explains  it  in  what  seems  very  beauti- 
ful, simple  reasoning. 


FAILURE   TO   GAIN  199 

Gentlemen,  you  remember  in  our  previous  lectures  we  dwelt 
upon  the  processes  of  putrefaction  and  fermentation.  We  spoke 
of  the  alkali-forming  protein,  of  the  rather  non-fermenting 
higher  carbohydrates,  and  the  fermenting  acid-forming  lower 
carbohydrates.  The  substances  which  were  of  great  influence 
in  correcting  the  constipated  stool  were  those  aiding  fermenta- 
tion, those  tending  to  make  the  intestinal  contents  acid;  and 
now  Freund  reminds  us  of  a  simple  little  chemical  process  which 
previously  had  been  overlooked,  viz.,  that  fat  does  not  readily 
form  soaps  in  the  presence  of  acids,  but  in  a  way  combines  with 
them  to  form  the  so-called  fatty  acids.  Soaps  in  the  presence 
of  acids  are  completely  split  up,  just  as  if  they  were  salts.  Gen- 
tlemen, do  you  grasp  the  importance  of  this  contribution  of 
Freund?  Think  of  it  carefully  for  a  moment.  If  this  be  true, 
soap  formation  is  a  result  arid  not  a  cause.  Soap  formation  is 
simply  a  symptom  of  the  intestinal  reaction  and  not  a  factor 
affecting  it.  Feeding  substances  like  protein,  which  alkalinize 
the  intestine,  favor  soap  formation  and  constipation.  Feeding 
substances  like  carbohydrate,  which  make  the  intestine  acid, 
break  up  the  soap  formation,  and  ca-use  the  looser  type  of  bowel 
movement.  Gentlemen,  I  urge  you  to  give  this  matter  careful 
consideration,  to  hold  the  principle  before  you  at  all  times, 
because  in  mastering  it  you  have  mastered  one  of  the  great 
causes  of  constipation  in  infants.  ''Fat  in  an  alkaline  intestine 
forms  soaps;  in  an  add  intestine,  fatty  acid." 

And  now,  if  this  great  mass  of  careful  observation  and  scien- 
tific experiment  proves  to  us  that  the  constipated  soapy  stool  is 
an  effect  and  not  a  cause,  are  we  any  closer  to  a  clearer  under- 
standing of  the  picture  of  milk  injury?  With  true  American 
lack  of  respect  for  dignity  and  title  one  day  I  assailed  Finkel- 
stein  in  a  corner  of  his  great  institution,  from  which  the  modest 
little  man  could  not  escape,  and  asked  him  to  make  the  matter 
clear  to  me.  I  never  left  him  until,  filled  with  wonder  and  ad- 
miration, I  had  obtained  his  own  personal  viewpoint.  He  re- 
minded me  that  in  feeding  a  baby  we  must  consider  the  food, 
the  intestine,  and  by  all  means  that  factor  which  so  frequently 
and  at  such  tremendous  cost  is  overlooked  by  men  speaking 
exclusively  of  " gastro-intestinal  disease"  rather  than  "dis- 
turbance of  nutrition, " — the  needs  of  the  child's  whole  body.  He  re- 


200  INFANT  FEEDING    (CHICAGO  METHODS) 

minded  me  that  in  feeding  Keller's  Malt  Soup  one  reduces  the 
fat,  but  at  the  same  time  increases  markedly  the  carbohydrate. 
Simple  reasoning,  simple  skepticism,  forces  the  question,  "How 
does  one  know  that  this  gain,  that  this  recovery,  was  due  to  the 
reduction  of  fat?  Is  it  not  just  as  reasonable  to  assume  that 
the  increase  of  carbohydrate  was  a  factor  of  equal  or  even  greater 
importance?  Is  it  not  likely  that  children  with  weak  constitu- 
tions, children  recovering  from  infections,  children  suffering 
from  neglect,  need  more  carbohydrate,  more  energy,  than  does 
the  normal  baby?  Is  not  the  primary  consideration  in  these 
cases  the  demands  of  the  child's  body  rather  than  the  condition  of 
his  digestive  tract?"  Have  you  forgotten  the  striking  statement 
of  Naunyn,  "The  fat  burns  in  the  fire  of  the  carbohydrate"? 
With  such  a  remarkable  viewpoint,  the  condition  of  the  digestive 
tract  fades  into  insignificance  before  the  primary  consideration 
of  the  child's  body.  The  child's  vigor  and  strength  depend  upon 
the  amount  of  carbohydrate  offered,  and  are  perfectly  inde- 
pendent of  the  reaction  of  the  intestinal  tract.  Whether  the 
fat  in  the  stool  is  excreted  in  the  form  of  soap  or  whether  it  is 
excreted  as  fatty  acid  depends  upon  the  reaction  of  the  intestinal 
contents.  If  the  contents  are  alkaline,  soaps  are  formed;  if 
acid,  fatty  acids  result.  In  Keller's  Malt  Soup  we  have  a 
mixture  ideal  for  creating  an  acid  condition  in  the  intestine. 
Low  protein  from  the  dilution  of  the  milk  lessens  alkali  forma- 
tion ;  high  carbohydrate  favors  acid.  Due  to  this  acid,  the  fat 
soaps  are  split  up  and  constipation  corrected;  but  the  great 
benefit  to  the  child — the  gain  in  weight,  the  improved  tone  of  the 
muscles,  the  returning  elasticity  to  the  skin — depends  not  upon 
the  correction  of  the  stool,  but  upon  the  increased  supply  of 
carbohydrate  offered  to  the  needy  tissues. 

It  was  for  this  reason  that  Finkelstein  introduced  the  term 
"disturbed  balance."  He  meant  to  imply  that  the  primary 
fault  was  not  one  of  fat  injury,  was  not  one  of  chronic  fat  in- 
digestion, as  is  the  viewpoint  of  so  many  men,  but  that  the 
trouble  lay  in  a  disturbed  balance  between  carbohydrate  and 
fat,  perhaps  carbohydrate  and  protein,  the  body  not  receiving 
enough  carbohydrate  to  satisfy  its  wants,  probably  not  receiv- 
ing enough  carbohydrate  to  perform  successfully  the  metabohsm 
of  the  fat.     This  viewpoint  in  a  striking  way  makes  clear  to  us 


FAILURE   TO   GAIN 


201 


the  brilliant  success  from  feeding  of  breast  milk.  Breast  milk 
offers  the  body  high  carbohydrate;  breast  milk,  with  its  high 
carbohydrate  and  low  protein,  establishes  processes  of  fermen- 
tation in  the  intestinal  tract  and  cures  the  constipation. 

This  viewpoint,  perhaps,  does  not  explain  every  case;  perhaps 
some  cases  really  are  due  to  primary  fat  indigestion;  but  at 
any  rate  we  learn  much  from  this  conception,  and  a  great  group 
of  cases  becomes  clear.  Probably  in  the  majority  of  cases,  as 
shown  by  the  results  with  breast  milk,  the  fat  is  indeed  only  a 
secondary  factor. 

Gentlemen,  now  you  see  why  I  have  tried  to  go  into  detail. 
If  you  have  followed  me  carefully;  if  you  have  understood  the 
principles  which  I  am  trying  to  make  clear,  you  have  the  key 
to  the  majority  of  cases  of  constipation  which  you  meet. 

You  see  also  how  modem  clinical  medicine  can  never  be 
separated  from  chemistry,  physiology,  and  the  allied  sciences. 
The  physician  needs  them  all  for  complete  understanding. 

The  diagnosis  of  this  condition  is  easy.  In  practice  you  will 
have  to  distinguish  it  only  from  inanition,  i.  e.,  hunger;  in  the 
latter,  an  increase  of  a  half-ounce  or  an  ounce  to  each  feeding 
will  result  in  rapid  cure.  In  the  true  case  of  disturbed  balance 
no  improvement  follows. 

Treatment. — For  the  young  baby  breast  milk,  which  is  always 
the  ideal  food,  is  the  best  treatment.  In  offering  breast  milk, 
let  me  warn  you  of  a  httle  complication,  simple  in  physiology, 
ignorance  of  which,  however,  may  lead  to  unpleasant  results. 
To  illustrate  (Fig.  11): 


7  0* 
6  oz 
5  OS 

4    02 

3  oz 

2    02 

1  oz 

^ 

,.-• 

A 

, — > 

/ 

/ 

* 

A 

— N 

^ 

/ 

\ 

/ 

/ 

y 

^ 

>^ 

^_ 

Fig.  11. 


202  INFANT   FEEDING    (CHICAGO   METHODS) 

At  A  we  have  changed  the  mixture  of  cow's  milk  to  one  of 
breast  milk.  A  loss  of  several  ounces  occurs,  lasting  several 
days.  What  is  the  explanation?  Can  any  of  you  grasp  why  a 
loss  of  weight  should  result  from  feeding  breast  milk?  The 
answer  is  found  in  the  simplest  physiology.  In  our  first  lecture 
we  told  you  that  cow's  milk  was  much  richer  in  mineral  matter 
than  breast  milk.  In  our  second  lecture  we  told  that  minerals, 
particularly  sodium,  were  important  in  binding  water  to  the 
tissues.  If  our  baby  had  been  getting  a  mixture  of  three-quar- 
ters of  a  quart  of  cow's  milk,  he  would  be  getting  5.7  grams  of 
salt — over  a  teaspoon.  The  change  to  three-quarters  of  a 
quart  of  breast  milk  reduces  his  salt  intake  to  13/^  grams.  You 
see  what  reduction  occurs  in  the  mineral  matter  of  his  diet. 
For  this  reason,  until  he  gets  properly  adjusted,  water  leaves  the 
body,  with  the  resulting  drop  of  several  ounces  in  the  weight 
curve.  This  loss  is  not  due  to  poor  breast  milk,  is  not  due  to 
insufficient  breast  milk,  but  to  perfectly  normal  breast  milk,  and 
a  knowledge  of  the  simple  explanation  will  save  the  mother,  the 
wet-nurse,  and  incidentally  you,  much  worry. 

If  artificial  feeding  is  to  be  employed,  what  shall  be  our  pro- 
cedure? Do  we  need  Keller's  Malt  Soup?  No;  but  we  do 
need  the  principles  upon  which  it  is  based.  We  wish  to  offer 
more  carbohydrate,  more  energy  to  the  baby's  tissues;  we  wish 
and  must  do  this  without  injuring  the  intestinal  tract.  In  our 
next  lecture  we  shall  learn  that  mixtures  of  high  carbohydrate  in 
connection  with  high  fat,  particularly  in  connection  with  concen- 
trated whey  of  cow's  milk,  are  dangerous  from  the  intestinal 
viewpoint.  We,  therefore,  dilute  our  milk,  not  with  the  idea  of 
diluting  the  fat  exclusively,  but  of  simply  making  up  a  mixture 
which  will  enable  us  to  offer  to  the  tissues  higher  carbohydrate 
without  causing  intestinal  complications.  We  dilute  to  one- 
third,  adding  two-thirds  water,  and  then  gradually  increase 
carbohydrate  until  we  get  the  improvement  of  the  general  con- 
dition and  the  more  normal  stool.  Ordinary  cane-sugar  is  the 
simplest  and  cheapest  carbohydrate  to  use.  One  word  of  warn- 
ing, however,  in  employing  it.  It  may  become  necessary  to  add 
more  than  six  or  eight  teaspoons  to  a  quart  of  the  mixture  in 
order  to  get  the  physiological  results.  Under  such  circum- 
stances the  mother  and  babe  rebel  at  the  sweet  taste;  therefore, 


FAILURE   TO   GAIN  203 

if  it  becomes  necessary  to  increase  over  six  to  eight  teaspoons, 
it  is  wdse  to  add  some  easily  fermentable  carbohydrate  less  sweet 
to  the  taste.  This  can  be  done  in  the  form  of  the  above-said 
malt  soup  extract.  Don't  make  the  mistake,  however,  of  order- 
ing pure  malt  extract.  This  does  not  mix  so  readily  with  the 
milk,  and  you  may  get  into  difficulties  with  the  mother;  but 
show  your  superior  knowledge  by  impressing  her  with  the  neces- 
sity of  getting  malt  soup  extract.     Several  concerns  put  this  up. 

In  children  over  two  or  three  months  of  age,  remember  that 
one-third  milk  is  not  sufficient  to  provide  for  continued  growth. 
After  a  short  time  one  cautiously  must  increase  the  concentra- 
tion of  the  milk.  The  increased  protein  temporarily  may  cause 
an  alkaline  reaction  to  the  intestine  with  a  renewal  of  soap  for- 
mation and  constipation.  This  can  be  combated  readily  by 
additional  increase  of  carbohydrate. 

One  point  in  the  treatment,  let  me  impress  you,  is  what  you 
should  not  do.  Now  that  you  understand  the  underlying  prin- 
ciples, you  see  how  utterly  unreasonable,  how  absolutely  with- 
out scruple,  is  the  physician  who  drugs  these  patients,  treating 
their  constipation  with  calomel,  castor  oil,  and  other  cathartics. 
At  our  hospital  at  home  Dr.  Abt  and  his  associate.  Dr.  Jampohs, 
some  years  ago  made  interesting  observations  on  perfectly 
normal  babies.  Feeding  a  fine  healthy  baby  a  therapeutic  dose 
of  these  drugs  caused  the  appearance  of  blood  in  the  stool — not 
in  large  quantities,  but  easily  detected  chemically.  Just  think 
of  that,  gentlemen;  feeding  a  perfectly  healthy,  normal  infant 
medicinal  doses  of  calomel  produces  such  irritation  in  the  in- 
testine as  to  make  blood  appear  in  the  stool!  What  a  crime  is 
it,  then,  to  offer  a  little  child  suffering  from  a  condition  of  dis- 
turbed balance  these  strong  intestinal  irritants;  to  try  to  over- 
come constipation,  not  by  reason  and  principle,  but  by  brute 
force!     What  this  baby  needs  is  not  medicine:  he  needs  sugar. 

Gentlemen,  we  are  now  temporarily  going  to  leave  Czemy. 
Remember  his  great  service  to  us — his  service  in  giving  us  the 
conception  of  disturbance  of  nutrition;  his  service  in  casting 
doubt  upon  the  indigestibility  of  protein;  his  service  in  recog- 
nizing food  as  an  important  factor  in  nutritional  disease.  What 
have  we  learned  from  this  lengthy,  perhaps  comphcated,  dis- 
cussion?   We  have  learned  to  think.    Only  the  light  shed  by 


204  INFANT   FEEDING    (CHICAGO   METHODS) 

time,  by  distance,  by  laboratory  experiments,  stimulated  by 
the  keenest  clinical  observations,  could  make  us  change  alle- 
giance to  Czerny's  first  idea.  Every  great  pediatrician  who 
was  able  to  read  these  writings  and  comprehend  them  was  in- 
fluenced. The  very  foundation  of  pediatrics  was  shaken.  Now, 
from  across  the  space  separating  us  by  years  from  Czerny's 
first  work  we  ask  ourselves,  "Did  we  not  all  err  alike?  Did 
we  not  all  make  the  same  fundamental  error?"  We  were  stirred 
by  the  brilliant  conception  of  disturbance  of  nutrition;  we 
temporarily  lost  sight  of  this  in  our  keen  interest  in  one  symp- 
tom— the  stool.  In  focusing  our  attention  upon  the  stool  we 
lost  all  sense  of  proportion  in  the  discovery  of  the  soap.  In 
this  maze  of  thought  we  lost  sight  of  the  relation  of  fat  to  the 
other  elements  in  the  milk;  we  lost  sight  of  the  fact  that  fat  in 
an  acid  intestine  makes  fatty  acids;  in  an  alkaline  intestine, 
makes  soaps.  Not  that  our  observations  were  without  value  or 
interest:  much  good  has  resulted.  But  they  were  in  entire 
disproportion  to  the  great  chnical  picture.  Only  careful,  fre- 
quently repeated,  accurate  bedside  study  resulted  in  putting 
us  again  upon  the  right  path.  Just  as  we  had  forgotten  to  note 
the  relation  of  the  fat  to  the  other  elements  of  the  milk,  so  had 
we  forgotten  to  note  the  relation  of  the  symptom — the  consti- 
pated stool — to  the  main  clinical  picture.  Just  as  our  exclusive 
attention  to  the  fat  had  led  us  astray,  so  did  our  exclusive  at- 
tention to  the  stool  divert  us  from  our  original  broad  conception 
of  disturbance  of  nutrition.  Gentlemen,  what  have  we  learned? 
We  have  learned  that  if  we  wish  to  err  only  slightly,  if  we  wish 
to  have  an  anchor  that  will  hold  us  secure,  let  us  never  forget 
that  first,  foremost,  above  everything  else,  the  fundamental 
truth  is  to  be  found  in  careful,  conscientious  chnical  observation 
and  study. 

What  is  the  practical  significance  of  this  lengthy  discourse? 
If  a  constipated  baby  is  not  gaining  upon  a  well-regulated  diet, 
carefully  increase  it.  If  he  still  does  not  gain,  make  up  a  mix- 
ture with  a  higher  percentage  of  fermentable  carbohydrate 
than  was  contained  in  the  original  formula,  and  increase  gradu- 
ally this  carbohydrate  until  improvement  occurs. 


LECTURE  V 
THE  STATES  OF  DYSPEPSIA  AND  INTOXICATION 

Gentlemen,  if  our  last  lecture  was  important  from  a  stand- 
point of  therapy,  today's  lecture  is  vital,  for  it  concerns  life. 
You  remember  at  our  last  meeting  we  spoke  of  Czemy's  new 
viewpoint,  "disturbance  of  nutrition."  We  showed  how  he 
introduced  food  as  a  factor  in  causing  disease  and  how  he  laid 
particular  importance  on  fat.  He  doubted  the  indigestibihty  of 
protein;  he  gave  us  an  etiological  classification;  due  to  this 
etiological  classification,  to  this  concentration,  perhaps,  on  one 
causative  factor,  we  became  side-tracked  and  focused  too  care- 
fully upon  one  symptom — the  stool.  Finkelstein,  you  re- 
member, accepted  the  \4ewpoint  of  "disturbance  of  nutrition," 
agreed  that  infection  and  constitution  were  factors,  but  enlarged 
greatly  the  importance  of  food.  To  him  most  disturbances, 
including  even  the  diarrheas,  were  due  not  to  infections,  but 
practically  entirely  to  food  alone.  Clinical  pictures  to  be 
brought  about  by  improper  feeding  were  four: 

The  picture  of  milk  injury  he  saw  just  as  did  Czerny,  but  for 
reasons  which  we  stated  he  changed  the  name  to  "disturbed 
balance."  His  tremendous  contribution  in  this  realm  was  in- 
cluding diarrheal  disease  in  this  group.  To  him  the  majority  of 
diarrheas  do  not  belong  to  the  infectious  group  of  Czerny;  do 
not  belong  either  to  (a)  those  caused  by  specific  bacterial  in- 
fection of  the  intestine  or  to  (6)  those  resulting  from  milk 
spoiled  by  bacterial  growth,  but  do  belong  to  the  group  of  dis- 
turbances arising  from  the  feeding  of  good,  wholesome,  pure 
milk  made  into  improper  mixtures. 

The  history  of  the  observation  and  development  of  the  food 
basis  for  diarrhea  is  fascinating.  The  first  stimulus  came  to 
Finkelstein  and  his  assistants  with  the  appearance,  in  their 
great  institution,  of  a  number  of  cases  of  severe  diarrhea — 

gastro-enteritis,  as  they  might  then  have  been  called,  or  dis- 

205 


206  INFANT  FEEDING    (CHICAGO   METHODS) 

turbances  of  nutrition  on  the  basis  of  infection,  as  Czemy  would 
have  said.  Perhaps,  in  a  way,  it  was  Czerny's  conception  of 
food  disturbance  that  led  them  to  investigate  carefully  condi- 
tions in  the  diet  kitchen.  To  their  interest  and  amazement 
they  discovered  that  by  an  error,  many  mixtures  contained 
imusually  high  quantities  of  sugar.  Could  the  sugar  be  a  causa- 
tive factor? 

Full  of  curiosity,  they  fed  babies  large  quantities  of  sugar, 
produced  severe  diarrheal  disease,  and  gave  to  the  pediatrics 
world  one  of  our  most  wonderful  contributions.  Not  only  could 
high  fat  and  low  sugar  produce  a  condition  of  disturbed  balance, 
but  high  sugar,  on  the  other  hand,  could  produce  severest  diar- 
rheal disease.  For  the  moment  we  see  Finkelstein  following  the 
same  error  of  Czemy,  focusing  too  carefully  upon  the  stool, 
upon  one  symptom,  forgetting  the  big  clinical  picture  and  laying 
blame  for  almost  ever>'  case  of  bad  diarrhea  on  too  much  carbo- 
hydrate in  the  food.     Not  long,  however,  before  he  saw  his  error. 

The  same  objection  applied  to  this  view  as  did  to  the  original 
idea  of  Czemy.  Breast  milk,  the  ideal  food,  contains  a  large 
quantity  of  carbohydrate, — easily  fermentable  carbohydrate, — 
but  children  when  fed  breast  milk  do  not  develop  these  deadly 
diseases.  There  must  be  some  other  factor — some  other  in- 
fluence. This  is  simple  reasoning,  simple  common  sense.  Care- 
ful clinical  study  again  guides  us  along  the  right  path. 

At  this  time  Ludwig  F.  Meyer,  Finkelstein's  first  assistant, 
made  an  important  contribution.  While  his  experiments  are 
open  to  great  criticism;  while  in  the  light  of  our  present  knowl- 
edge they  can  be  attacked  from  all  sides,  nevertheless,  in  their 
day  they  served  their  purpose.  He  took  cow's  milk  and  breast 
milk,  separated  them  each  into  curd  and  whey,  as,  for  example 
(Fig.  12), 

Breast  Milk  Caeoin^       ri^Vhey 

-  Cow '8  Milk  Casein'^        '^Whey 

Fig.  12. 

and  after  having  divided  these  mixtures,  he  crisscrossed,  adding 
the  casein  of  cow's  milk  to  the  whey  of  breast  milk,  and  the 


THE   STATES   OF  DYSPEPSIA  AND   INTOXICATION  207 

casein  of  breast  milk  to  the  whey  of  cow's  milk.  Offering  these 
mixtures  to  children  sick  with  diarrheal  disease  resulted  in  sharp 
differences.  Those  getting  the  mixture  containing  the  whey  of 
breast  milk  made  good  recoveries;  those  getting  the  mixture 
with  the  whey  of  cow's  milk  did  not  do  so  well. 

Gentlemen,  although  this  experiment  is  open  to  great  criti- 
cism, it  served  its  purpose.  It  called  to  our  attention,  for  the 
very  first  time,  the  whey  of  cow's  milk.  Now  we  hear  of  the 
whey  as  a  factor  in  producing  disturbance.  We  Jiave  heard  of 
protein,  fat,  carbohydrate,  and  now  we  hear  whey;  and,  after  all, 
is  it  not  strange  that  for  so  many  years  we  have  neglected  this 
portion  of  the  milk?  Is  it  not  Ukely  that  whey,  with  almost 
four  times  the  salt  content  of  breast  milk,  also  could  exert  harm- 
ful influences  upon  the  intestine,  perhaps  due  to  osmotic  con- 
ditions or  to  who  knows  what?  To  Ludwig  F.  Meyer,  then, 
are  we  indebted  for  this  new  inspiration. 

While  these  observations  were  going  on,  clinical  study  again 
was  bringing  Finkelstein  toward  the  ultimate  truth.  Increasing 
carbohydrate  in  some  milk  mixtures  resulted  in  diarrhea.  In- 
creasing carbohydrate  in  others,  to  his  mystification,  had  no 
such  effect.  What  could  be  the  explanation?  The  solution 
was  discovered  in  combining  the  above  two  chnical  experiments. 
When  carbohydrate  is  added  to  mixtures  of  cow's  milk  rich  in 
whey,  diarrhea  results;  when  carbohydrate  is  added  to  mixtures 
poor  in  whey,  no  diarrhea  results.  The  more  concentrated  the 
whey,  the  worse  the  diarrhea!  Thus,  you  see,  adding  carbo- 
hydrate to  buttermilk  or  to  skimmed  milk  will  make  a  laxative 
combination — these  mixtures  containing  all  the  whey  elements 
of  the  milk.  Adchng  carbohydrate  to  pure  whey  would  cause  an 
intense  diarrhea.  I  should  advise  you  not  to  try  this.  What 
factor  in  the  whey  causes  these  symptoms  I  do  not  know.  Per- 
haps it  is  the  salt.  As  I  have  said  so  frequently,  "This  is  clinical 
observation." 

It  is  human,  however,  to  wish  things  clear;  to  have  a  picture 
to  hold  before  us,  a  guide  for  our  thoughts.  I  can  offer  the 
explanation  that  has  been  given  by  our  teachers.  Do  not 
take  it  as  an  absolute  truth,  but  simply  as  an  illustration  of  the 
processes  of  modern  reasoning.  How  can  a  mixture  of  whey  and 
carbohydrate  produce  these  results? 


208  INFANT   FEEDING    (CHICAGO   METHODS) 

Normally,  billions  and  billions  of  bacteria  live  in  the  large 
intestine.  The  small  intestine  is  relatively  sterile.  Only  at 
times  when  food  is  digested  are  bacteria  fomid  in  any  amoimt 
in  the  upper  tract.  With  the  disappearance  of  food,  with  its 
absorption  through  the  intestinal  wall,  the  bacteria  rapidly  go 
back  to  their  home,  to  their  normal  environs  in  the  large  in- 
testine. Those  left  in  the  upper  tract  are  killed,  probably  by 
the  intestinal  cells  and  by  the  digestive  juices. 

Postmortem  examination  in  many  cases  of  severe  diarrhea, 
however,  reveals  the  upper  intestine  swarming  with  micro- 
organisms— not  abnormal  ones,  but  simply  those  which  normally 
live  in  the  lower  bowel.  Gentlemen,  what  has  happened? 
Normally  the  upper  intestine  is  able  to  keep  its  contents  sterile. 
Something  must  have  impaired  this  function.  Is  it  not  possible 
that  the  digestive  juices  and  the  activities  of  the  epithehal  cells 
have  been  handicapped  by  the  high  salt  content,  perhaps  by  the 
changed  salt  relations  of  the  cow's-milk  whey?  Moro's  experi- 
ments would  tend  to  confirm  this  hypothesis.  In  carefully 
conducted  researches  he  and  his  assistants  showed  that  the  in- 
testinal cells  are  more  efficient  when  active  in  a  medium  of 
breast-milk  whey  than  of  cow's-milk  whey. 

Once  injured,  these  intestinal  cells  cannot  suppress  bacterial 
growth.  Bacteria  will  thrive  and  prosper,  and  now,  when  car- 
bohydrate is  introduced,  before  the  intestinal  digestive  enzjones 
can  alter  it,  prepare  it  for  assimilation,  and  carry  it  through  the 
intestinal  wall,  the  hungering  bacteria  have  seized  it,  fermented 
it,  and  changed  it  to  the  irritating  lower  fatty  acids,  such  as 
acetic,  butyric,  and  formic.  Gentlemen,  do  you  remember  that 
in  the  first  lecture  and  in  the  second,  also,  we  tried  to  impress 
upon  you  that  when  bacteria  attack  carbohydrate  the  process 
is  known  as  fermentation  and  acid  results?  Now  you  under- 
stand why.  The  injured  intestinal  epithelium  can  no  longer 
exercise  control  and  fermentation  proceeds  rapidly.  A  tremen- 
dous quantity  of  irritating  products  results,  and  causes  a  severe, 
acid,  watery  diarrhea.  Such  is  what  we  reasonably  may  be- 
lieve. Chnical  observation  has  painted  a  picture  in  abnormal 
physiology. 

To  return  to  the  bedside.     Diarrheas  are  of  two  types: 


THE   STATES   OF   DYSPEPSIA   AND   INTOXICATION 


209 


(a)  A  mild  attack,  with  symptoms  described  as  mild  gastro- 
enteritis or  mild  summer  complaint. 

(6)  An  intense  attack,  often  deadly  in  nature,  described  as 
severe  gastro-enteritis,  severe  ileocolitis,  or  cholera  infantum. 

The  first  of  these  conditions  Finkelstein  called  dyspepsia;  the 
second,  intoxication,  not  because  he  had  isolated  any  toxin,  but 
because  from  a  clinical  point  of  view  the  little  patient  appeared 
poisoned.  This,  you  remember,  is  a  clinical  classification.  The 
picture  is  constantly  before  us.  Explanations  will  be  varied, 
causes  amphfied,  new  factors  discovered ;  but  the  clinical  picture 
remains  unchanged. 

DYSPEPSIA 

This  is  one  of  the  most  frequent  ailments  you  meet.  The 
mother  brings  the  babe  mainly  for  relief  of  intestinal  symptoms. 
The  child  has  mild  diarrhea — five,  six,  or  eight  watery,  green, 
sour-smelUng  stools  with  mucus;  vomits  occasionally  and  has 
colic. 

Careful  history  shows  nothing  of  importance  other  than  per- 
haps a  slight  cold.  Baby's  sleep  is  disturbed,  and  for  a  few  days 
he  has  not  been  gaining. 


Fig.  13. 


Examination  (Fig.  13)  shows  that  he  is  not  very  sick — he  is 
sUghtly  undernourished,  pale,  and  restless,  perhaps  peevish  and 
irritable.   Consciousness  is  not  affected.    There  may  be  shadows 
14 


210  INFANT   FEEDING    (CHICAGO   METHODS) 

under  the  eyes  and  the  abdomen  distended.  Temperature, 
pulse,  and  respiration,  other  than  possibly  a  slight  fever,  reveal 
no  important  change. 

Gentlemen,  we  have  spoken  about  the  reactions  to  food  and 
to  hunger.  Addition  of  food  or  increase  of  diet  to  this  patient 
will  have  little  effect.  His  diarrhea  may  become  worse,  his 
general  symptoms  a  httle  increased,  but  he  will  show  no  radical 
change.  Withdrawal  of  food — absolute  hunger — causes  a  marked 
improvement.  Diarrhea  ceases  and  he  becomes  better,  brighter, 
and  happier.  There  may  be  a  moderate  loss  of  a  few  ounces  of 
weight  for  a  day  or  so,  but  then  the  curve  rapidly  swings  to 
normal. 

If  we  study  such  a  child  from  a  standpoint  of  metaboHsm; 
if  we  analyze  carefully  the  amoimt  of  food  taken  in  twenty-four 
hours  and  the  end-products  excreted  in  the  urine  and  the  stool 
for  twenty-four  hours,  we  find  the  following  changes: 

a.  Protein  excretion  is  slightly  increased. 

b.  Fat  is  not  changed  unless  the  child  has  been  receiving 
some  quantity  in  his  bottle.  Then  considerable  is  found  in  the 
stool. 

c.  Starch  may  be  found  in  the  stool,  particularly  if  baby  has 
been  receiving  a  starchy  diet. 

d.  There  may  be  a  slight  loss  of  mineral  matter,  chiefly  of 
sodium  and  potassium. 

e.  Most  striking  is  the  increased  excretion  of  the  irritating 
volatile  lower  fatty  acids,  such  as  acetic,  butyric,  and  formic. 

What  is  the  source  of  these  acids?  Czerny  would  have  said 
that  they  come  from  bacterial  infection  of  the  milk  outside  of 
the  body;  Finkelstein,  that  these  acids  are  produced  by  the 
normal  bacteria  of  the  intestine  attacking  the  carbohydrates  of 
the  milk  under  the  accelerating  influence  of  the  whey.  The 
splendid  studies  of  the  younger  men,  such  as  Barth,  Edelstein, 
and  others,  stimulated  by  these  controversies,  have  shown  that 
acid  formation  in  the  stool  is  infinitely  greater  than  acid 
formation  in  spoiled  milk.  Thus  they  must  be  created  in  the 
body. 

Just  as  clinical  study  enlarged  Gzerny's  idea  of  fat  injury,  so 
did  it  enlarge  Finkelstein's  idea  of  whey-sugar  injury.  New 
points  added  as  etiological  factors  are: 


THE   STATES   OF  DYSPEPSIA  AND   INTOXICATION  211 

I.  From  the  Standpoint  of  Food. 

A.  As  regards  good,  wholesome,  pure  milk,  the  factor 
which  Finkelstein  so  emphasized: 

(1)  Simple  overfeeding  is  a  frequent  cause. 

(2)  Particularly  is  overfeeding  with  sugar-whey  mix- 
tures a  factor.  This  was  Finkelstein's  first  great  con- 
tribution. 

(3)  In  a  medium  of  cow's-milk  whey,  high  sugar  plus 
fat  causes  these  diarrheas.  Many  men  lay  primary 
emphasis  upon  the  latter,  for  the  stools  show  great 
quantities  of  undigested  fat.  We  do  not  wish  to  be 
dogmatic.  Undoubtedly  high  fat,  particularly  if  not 
properly  digested,  can  produce  irritating  products  and 
diarrhea.  We  believe,  however,  the  more  important 
process  is  the  primary  fermentation  of  the  carbohy- 
drate, which  whisks  out  the  fat  in  the  resulting  diar- 
rhea, the  fat  appearing  as  a  neutral  secondary  element. 
We  believe  that  probably  the  fat  suffers  secondarily 
as  the  acids  from  sugar  fermentation  interfere  with 
the  digestive  enzymes.  These,  you  know,  work  best 
in  an  alkaline  medium. 

B.  As  Regards  Spoiled  Food. — From  the  viewpoint  of 
Czerny,  spoiled  milk  undoubtedly  at  times  provides  irri- 
tants to  the  intestine  sufficient  to  cause  these  symptoms 
— particularly  in  older  children,  during  the  simMner 
months,  are  spoiled  foods  of  all  sorts  important  agents. 

II.  We  have  relearned  the  value  of  constitution.  The  weaker 
the  baby,  the  more  is  he  predisposed. 

III.  Frequently  repeated  mild  infections,  as  coughs  and  colds, 
are  of  extreme  importance. 

IV.  Heat  and  improper  nursing  must  meet  with  our  consider- 
ation, and,  of  course,  time  will  add  new  influences  to  the 
list.  Probably  all  of  these  in  some  way  or  another  will 
increase  fermentation  in  the  intestines. 

From  this  viewpoint  you  see  how  relatively  unimportant  is 
examination  of  the  stool — I  mean,  relatively  unimportant  as  a 
strict  indication  for  therapy.  Jn  any  of  these  dyspeptic  stools, 
had  the  baby  been  fed  starch,  the  starch-granules  would  have 
been  whisked  through  by  the  increased  peristalsis;    had  he 


212  INFANT   FEEDING    (CHICAGO   METHODS) 

received  high  fat,  the  fat  would  have  appeared  in  large  quanti- 
ties. Had  we  focused  our  attention  exclusively  upon  the  stool, 
forgetting  the  more  general  considerations,  we  would  have  said, 
"This  is  a  disturbance  due  to  starch;  this  is  a  disturbance  due 
to  fat";  but  now,  as  Ludwig  F.  Meyer  in  his  pointed  way  once 
said  to  me,  "When  you  find  high  fat  in  the  stool,  seek  the  carbo- 
hydrate," 

Treatment. — The  treatment  based  upon  these  opinions  must 
be  self-evident  and  simple.  If  the  whey  is  a  factor  injuring  the 
intestine  and  permitting  bacteria  to  flourish  in  the  upper  tract, 
it  must  be  diluted.  If  carbohydrate  ferments,  we  must  give  it 
in  a  non-fermentable  form.  The  more  we  dilute  the  whe}^,  the 
more  we  reduce  the  factor  injuring  the  intestine,  the  safer  is 
it  to  give  carbohydrate.  Non-fermentable  carbohydrates,  we 
told  you,  are  composed  of  mixtures  of  dextrin  and  maltose  and 
can  be  offered  as  Mead's  Dextri-maltose.  More  fermentable 
are  Mellin's  Food,  Horlick's  Malt  Food  (not  Malted  Milk),  etc. 
Remember,  these  substances  are  carbohydrates,  and  under  no 
circumstances  baby  foods.  Dextri-maltose,  copied  from  Soxh- 
let's  Nahrzucker,  contains  most  dextrin,  and  is  therefore  the 
least  fermentable.  Borcherdt  also  puts  up  a  similar  prepara- 
tion. 

Our  treatment  then  for  these  milder  conditions  would  be: 

1.  Hunger  for  twelve  to  twenty-four  hours,  not  forgetting, 
however,  to  keep  up  a  sufficient  supply  of  water.  During  this 
hunger  period  the  baby's  vomiting  and  diarrhea  empty  his 
digestive  tract  of  all  irritants.  It  is  not  necessary  to  give  calo- 
mel and  castor  oil,  unless,  perhaps,  foreign  substances  have  been 
eaten;  for  the  baby,  as  a  rule,  can  well  take  care  of  himself. 
If  you  suspect  that  the  trouble  is  due  not  to  milk,  but  to  corn 
or  cucumbers  or  watermelon,  a  dose  of  castor  oil  and  a  mild 
colonic  flushing  may  do  no  harm,  if  given  once. 

2. .  After  this  hunger  period  we  start  food.  To  dilute  the  whey, 
we  give  one  part  milk,  two  parts  water.  To  this  mixture  we  add 
1  or  2  percent  of  non-fermentable  carbohydrate.  We  boil  these 
together  and  in  six  feedings  give  a  total  of  six  to  ten  ounces  in 
twenty-four  hours,  always  keeping  up  the  supply  of  water.  We 
gi'adually  increase  about  three  ounces  to  the  total  every  day  or 
two  until  we  have  reached  the  maximum,  depending  upon  the 


THE   STATES   OF   DYSPEPSIA   AND    INTOXICATION 


213 


baby's  age.  Then  gradually  we  increase  the  carbohydrate  to 
5  percent.  In  all  this  treatment  our  guide  must  be  not  so  much 
the  stool  as  the  baby's  weight  curve  (Fig.  14). 


I 

i 

s 

[ 

1 

1 

I 

1 

6 

) 

1 

0 

1 

1 

12  oz 
8  Oz 

4   02 

/ 

/ 

^-* 

>>^ 

/ 

\ 

,^ 

/ 

J 

> 

v 

J 

(! 

^ 

/' 

\ 

L 

f^ 

^ 

--^ 

^ 

Fig.  14. 


At  A  we  have  withdrawn  food;  a  loss  of  perhaps  seven  to 
eight  ounces  results  during  the  next  few  days. 

At  B,  after  twelve  to  twenty-four  hours'  hunger,  we  give  a 
day's  total  of  six  to  ten  ounces.  We  make  no  change  until  at 
C  the  curve  has  straightened,  and  then  we  cautiously  increase. 
Remember,  the  curve  is  the  index  of  the  general  nutrition,  and 
although  this  dyspepsia  is  almost  exclusively  a  local  intestinal 
affair,  still  the  loss  of  weight  resulting  from  improper  treatment 
proves  that  the  general  nutrition  also  can  and  does  suffer,  and 
if  we  keep  this  broad  picture  before  us  we  shall  less  likely  err 
badly. 

In  some  cases  physicians,  instead  of  giving  water  during  the 
first  day,  give  cereal  waters — barley  gruel,  etc.  This  often  is 
fully  as  efiicient  as  plain  water.  The  dangers,  however,  are 
two: 

a.  The  physician,  in  his  carelessness,  the  mother  not  knoudng 
that  barley  water  is  a  starvation  diet,  forgets  to  add  food,  and 
allows  the  baby  to  remain  on  barley  water  for  days.  After  a 
period  of  four,  five,  or  six  days  the  child  rapidly  develops  the 
condition  of  Czerny's  starch  injury,  or,  as  we  shall  call  it, 
"decomposition." 

6.  Sometimes,  after  the  baby  has  been  on  barley  water,  for 


214  INFANT   FEEDING    (CHICAGO   METHODS) 

reasons  which  are  not  clear,  upon  the  addition  of  milk  to  the 
diet,  fermentation  again  becomes  active  in  the  intestine  and 
diarrhea  returns. 

For  dyspepsias  in  older  children  the  same  principles  hold  good. 
We  shall  refer  to  them  later. 

Gentlemen,  suppose  we  are  ignorant  of  the  food  factor  in  this 
dyspepsia;  suppose  we  have  attributed  the  condition  to  some- 
thing elses  suppose  we  have  quieted  the  child  with  opiate  and 
allayed  the  mother's  fears ;  suppose  we  have  thoroughly  cleaned 
out  the  child  with  calomel  and  castor  oil ;  and  then  suppose,  in 
our  folly,  thinking  the  baby  must  have  food,  we  offer  the  child 
one  of  those  mixtures  high  in  the  whey  elements  of  the  milk  and 
rich  in  fermentable  carbohydrate,  such  as  buttermilk  with  sugar 
or  skimmed  milk  with  sugar — can  you  grasp  the  result? 

Shortly  we  are  called  to  see  a  desperately  sick  baby.  The 
child  is  feverish  and  lies  in  semi-stupor.  The  sunken  cheeks, 
the  sharp  nose,  the  ashen,  mud-colored,  wrinkled  skin,  the  cold 
extremities,  all  show  great  loss  of  weight  and  great  prostration. 
Intense  watery  diarrhea  drains  the  body  of  its  food,  pulls  out 
the  very  building-blocks  of  the  tissues.  The  pulse  is  rapid  and 
weak.  Lying  apathetically,  our  little  patient  takes  not  a  par- 
ticle of  interest  in  his  surroundings.  The  unclosed  lids  show  the 
glassy  eyes  fixed  imintelligently  upon  one  corner  of  the  room. 
Occasionally  he  wakes  for  a  moment,  looks  at  us,  cries  fretfully, 
and  again  wanders  off  into  apathy.  The  breathing  is  charac- 
teristic, deep,  tireless,  rapid,  unceasing,  like  the  air-hunger  of 
diabetic  coma.  Occasionally  one  of  the  almost  limp  extremities 
moves  slightly.  Sometimes  it  takes  a  cataleptic  attitude.  The 
arms,  particularly,  are  apt  to  assume  the  position  typical  of  a 
prize-fighter.     The  urine  may  show  sugar,  albumin,  and  casts. 

Examination  reveals  an  enlarged  liver. 

What  have  we  donef  We  have  produced  a  wonderful,  a  terri- 
ble, cHnical  picture.  We  have  produced  the  "  aUmentary  intoxi- 
cation" of  Finkelstein. 

Gentlemen,  we  spoke  about  the  importance  of  food  reactions. 
Listen  carefully:  If  in  this  stage  we  offer  our  patient  a  full 
bottle;  if  we  offer  him  any  large  quantity  of  food,  his  weight 
curve  sinks  precipitately,  vertically,  downward  to  rapid  death. 
We  have  killed  him.     No  surer  way  have  we  of  doing  this  than 


THE   STATES   OF   DYSPEPSIA   AND   INTOXICATION 


215 


by  offering  food;  no  surer  way  have  we  of  saving  him  than  by 
removing  food  (Fig.  15). 


Bays 

: 

I 

<k 

A 

i 

^ 

5 

1 

9  lb 
12  oz 
8  oz 

4  oz 
e  lb 

12  oz 
8  oz 

^ 

^ 

X. 

i 

k 

\ 

\ 

\ 

\ 

V 

\ 

\ 

JS 

_J 

; 

Fig.  15. 


In  the  period  of  his  dyspepsia,  if  at  point  A  we  have  mis- 
treated our  patient,  so  that  steady  progression  has  thrown  him 
into  the  stage  of  intoxication,  at  B  addition  of  food  brings  the 
fatal  drop;  withdrawal  of  food  straightens  out  the  curve  and 
the  child  is  saved.  What  more  beautiful  illustration  has  one  of 
the  effects  of  food  than  this  clinical  observation — than  this  so- 
called  "paradoxical  reaction  of  Finkelstein"?  The  food  which 
would  cause  a  normal  baby  to  gain,  causes  destruction;  the 
hunger  which  causes  a  normal  baby  to  lose,  is  salvation. 

What  processes  are  involved  in  this  radical  change,  in  the 
progress  of  the  mild  dyspepsia  to  the  deadly  intoxication?  Lis- 
ten carefully:  This  progress  is  one  of  transition  from  a  mild, 
local,  intestinal  disturbance  to  the  severest  "disturbance  of 
nutrition."  In  the  dyspepsia,  constitutional  symptoms  are 
mild.  The  acids  formed  slightly  irritate  the  mucous  membrane 
and  cause  diarrhea,  but  nutrition  is  not  badly  affected,  as  shown 
by  the  relatively  sHght  loss  of  weight.     Now  note  the  progress. 


216  INFANT   FEEDING    (CHICAGO   METHODS) 

Increasing  acid  formation  injures  the  intestinal  wall.  The  acids 
become  sufficient  to  interfere  with  the  digestive  enzymes.  Fat 
no  longer  is  properly  digested,  and  its  split  products  aid  in  in- 
creasing the  damage.  In  this  acid  medium  new  types  of  bac- 
teria flourish — bacteria  which  can  attack  the  fat,  producing 
intense  irritants. 

Before  these  combined 'assaults  the  intestinal  wall  begins  to 
fail.  The  membrane  remains  no  longer  impermeable  to  attack. 
Its  weakened  strength  cannot  be  detected  by  the  microscope: 
it  can  be  by  physiological  experiment.  Now  for  the  first  time 
undigested  food-substances  pass  the  membrane  into  the  body. 
We  have  not  seen  these  substances  enter,  but  our  examinations 
have  found  them  as  they  leave.  We  feed  children  in  this  con- 
dition lactose,  and  lactose  appears  in  the  urine.  We  feed  foreign 
protein,  and  foreign  protein  reappears.  Gentlemen,  the  process 
of  digestion  is  to  prepare  food-stuffs  for  the  use  of  the  tissues. 
Undigested  food  circulating  in  the  body  fluids  is  poison.  See 
the  possibilities  of  this  conception.  The  mild  dyspepsia  has 
progressed  so  that  now  the  entire  body  has  become  severely  and 
dangerously  involved. 

We  can  paint  any  picture.  We  see  undigested  protein  and 
poisonous  products  of  the  fat  taken  into  the  circulation.  We 
see  the  tissues  bathed  in  strong  solutions  of  sugar  and  of  salt. 
We  see  innumerable  products  of  bacterial  activity  rapidly  enter- 
ing the  system.     We  see  chaos  where  we  should  see  order. 

Small  wonder  at  the  multitude  of  clinical  symptoms.  Con- 
vulsions, strabismus,  and  cerebral  cry  may  suggest  meningitis. 
Gastro-intestinal  effects  may  be  great  enough  to  resemble 
cholera.  But  in  all  cases  remember  that  certain  symptoms  will 
be  constant :  the  rapid  loss  of  weight,  the  acidosis  breathing,  the 
disturbed  consciousness. 

The  examination  of  the  intake  and  the  total  excretion  of  these 
children,  in  contrast  to  the  mild  dyspepsia,  shows  considerable 
loss  of  body  substance.  Protein,  fat,  and  minerals  are  thrown 
out  by  the  rapid  intestinal  movements.  The  urine  shows  the 
most  profound  changes  of  metabolism.  There  is  a  tremendous 
loss  of  water,  due,  perhaps,  not  so  much  to  the  increased  bowel 
movements,  for  this  loss  is  compensated  by  the  decreased  urine, 
but  to  the  tireless,  rapid,  deep  respiration.     In  this  condition. 


THE   STATES   OF   DYSPEPSIA   AND   INTOXICATION 


217 


then,  we  are  dealing  with  an  infinitely  more  important  problem 
than  local  intestinal  disease.  As  tonsillitis  results  in  endocar- 
ditis; as  the  insignificant  wound  ends  in  deadly  tetanus,  so  may 
the  simple  dyspepsia  lead  to  a  profound  "disturbance  of  nutri- 
tion " — "alimentary  intoxication." 

Diagnosis. — The  history,  in  a  way,  makes  the  diagnosis.  Im- 
proper feeding,  followed  by  a  disturbance,  such  as  we  have 
described,  almost  invariably  is  "alimentary  intoxication."  How- 
ever, we  have  learned  from  more  recent  studies  not  to  focus  our 
hifetory  too  carefully  upon  feeding  alone,  but  to  recognize  new 
factors,  which,  by  their  effect  upon  the  baby's  general  condition, 
also  predispose.  To  these  we  referred  in  dyspepsia,  viz.,  age, 
constitution,  infections,  poor  nursing,  and  heat.  We  have 
learned  that  this  condition  never  develops  primarily  in  a  well 
child.  There  must  have  been  a  preceding  state  of  dyspepsia  or 
decomposition.    The  latter  we  consider  in  the  next  lecture. 

The  diagnosis  is  definitely  estabUshed  upon  withdrawal  of 
food  (Fig.  16). 


Days 

■ 

L 

; 

; 

5 

i 

I 

1 

> 

9  lb 
12  oz 
8  oz 
4  OS 
8  lb 

\ 

\ 

\ 

N 

^ 

\ 

. 

\ 

L 

\ 

\ 

1 

Fig.  16. 

If,  after  twenty-four  hours  of  hunger,  {Ke  loss  of  weight  ceases, 
the  temperature  drops  to  normal,  the  diarrhea  improves, — the 
latter,  however,  not  being  absolutely  essential, — we  make  a 
positive  diagnosis  of  alimentary  intoxication. 


218  INFANT   FEEDING    (CHICAGO   METHODS) 

Treatment. — 1.  Gentlemen,  during  the  first  twenty-four  hours 
the  child  rrmst  hunger.  During  this  day  the  diarrhea  and  the 
vomiting  will  empty  the  intestinal  tract  of  irritants. 

2.  Under  no  circumstances  shall  we  give  calomel,  castor  oil, 
or  any  other  irritating  drug.  Just  think!  The  intestines  are 
acting  as  rapidly  as  possible  to  rid  themselves  of  irritants.  They 
are  moving  just  as  quickly  as  they  can;  you  can't  make  them 
move  any  more  quickly;  all  that  you  are  doing  with  these  drugs 
is  to  increase  injury.  What  the  intestine  needs  is  not  stimula- 
tion: it  needs  a  resf.  For  this  same  reason  we  would  not  injure 
the  stomach  and  intestines  by  getting  a  big  pump  and  repeatedly 
washing  out  the  stomach  and  flushing  out  the  bowels.  Let 
them  alone!  They  will  take  care  of  themselves  if  you  give  them 
only  half  a  chance.  If  your  aim  in  using  these  drugs  is  intestinal 
asepsis,  your  hope  is  in  vain!  No  drug  is  known  which  will 
make  the  intestine  sterile.  Indeed,  animals  raised  with  sterile 
intestinal  tracts  hve  only  a  short  time.  Barrels  of  medicine 
haven't  nearly  the  effect  of  a  slight  change  in  diet. 

In  addition  to  the  great  principle  of  physiologic  rest  during 
these  twenty-four  hours  we  can  aid  our  Uttle  patient  in  other 
ways: 

3.  He  is  suffering  greatly  from  loss  of  water:  we  must  supply 
fluids.     Give  him  all  the  water  he  wants. 

4.  The  use  of  a  little  salt  will  aid  him  in  retaining  water  in  his 
body.  Simply  take  a  little  surgical  salt  solution — physiological 
salt  solution,  made  by  adding  a  teaspoon  of  salt  to  a  pint  of 
water;  dilute  this  to  half -strength,  sweeten  it  with  a  little  sac- 
charine, and  offer  the  baby  three  to  four  ounces  by  mouth  during 
the  first  twenty-four  hours.  Don't  give  over  this  amount,  or 
you  will  produce  edema  and  throw  too  great  a  strain  upon  the 
heart.     Edema  readily  results. 

5.  Our  little  child  may  need  to  be  stimulated.  Under  these 
conditions,  brandy  in  doses  of  10  to  15  drops  every  few  hours; 
caJfein  citrate,  in  doses  of  3^  grain,  may  be  given  by  mouth. 
Infinitely  more  effective  is  the  hypodermic  use  of  10  to  15 
minims  of  a  10  percent  solution  of  camphor  in  oil,  repeated,  when 
necessary,  every  few  hours.  Personally  I  have  come  to  place 
more  and  more  confidence  in  adrenalin.  One  hears  very  little 
of  this  in  medical  discussions;   but,  from  my  own  observations, 


THE   STATES   OF   DYSPEPSIA   AND    INTOXICATION  219 

I  am  absolutely  convinced  that  in  the  failing  pulse  and  sinking 
blood-pressure  of  this  condition,  just  as  in  surgical  shock,  hypo- 
dermic injections  of  two  to  three  minims,  repeated  every  two 
or  three  hours,  are  of  great  value.  In  my  own  studies  I  have 
found  that  the  blood-pressure  is  raised  and  maintained  for 
periods  of  one-half  hour  following  injection,  probably  by  the 
gradual  absorption  resulting  from  subcutaneous  rather  than 
intravenous  use. 

6.  During  this  first  day,  treatment  of  the  mother  is  an  impor- 
tant consideration.  She,  in  her  maternal  anxiety,  demands  that 
we  do  something.  The  substitution  of  tea  for  water  is  a  great 
help.  From  our  standpoint,  children  take  it  well,  Uke  it,  and 
we  supply  fluid  to  the  tissues.  We  can  explain  to  the  mother, 
however,  that  in  tea  we  have  caffein,  which  is  a  great  stimulant; 
tannic  acid,  which  will  tend  to  combat  the  diarrhea,  and  we 
can  make  the  matter  more  impressive  by  adding  a  Httle  sac- 
charine tablet  for  sweetening.  We  can  busy  the  mother,  during 
the  first  day,  with  the  general  care  of  the  baby,  keeping  him 
warm,  offering  with  a  medicine-dropper  small  doses  of  salt 
solution  and  perhaps  a  little  medicine  at  regular  intervals,  but 
under  no  circumstances  shall  we  diverge  radically  from  our  prin- 
ciples. 

7.  What  medication  shall  we  use  for  the  intestine?  Gentle- 
men, if  you  have  understood  the  principles  of  this  disturbance, 
you  see  that  a  httle  alkali  can  be  reasonable  and  logical.  Chalk 
mixture,  with  its  calcium,  can  be  given  in  doses  of  several  tea- 
spoons every  few  hours.  It  is  interesting  to  see  how  the  older 
men  empirically  arrived  at  this  remedy;  but,  gentlemen,  under 
no  circumstances  place  your  faith  in  medicine;  medicines  are 
simply  insignificant  aids  in  our  treatment,  compared  to  the  enor- 
mous influence  exerted  by  food. 

8.  While  in  the  stage  of  simple  dyspepsia,  ordinary  dilution  of 
the  milk  and  reduction  of  carbohydrate  suffice  for  a  cure,  in 
intoxication  we  are  reduced  to  the  use  of  two  foods  only.  These 
are  breast  milk  or,  if  this  is  not  obtainable,  "Eiweiss  Milch," 
or  albumin  milk  of  Finkelstein  and  Meyer. 

The  principles  of  this  food  depend  upon  ordinary  common 
sense.  If  carbohydrate  ferments,  it  must  be  reduced.  If  whey 
so  injures  the  intestine  as  to  enhance  fermentation,  the  whey 


220  INFANT   FEEDING    (CHICAGO   METHODS) 

must  be  diluted.  If  casein,  by  calling  forth  alkaline  intestinal 
juice,  by  aiding  putrefaction,  by  combining  with  calcium,  over- 
comes fermentation  and  makes  the  intestine  alkaline,  protein 
must  be  increased.  With  this  object  in  view  Finkelstein  and 
Meyer  set  about  making  the  albumin  milk.  It  was  originally 
made  as  follows: 

(a)  To  one  quart  of  raw  milk  add  enough  ferment  to  cause 
coagulation  and  foraiation  of  large  casein  curds.  Any  milk- 
coagulating  ferment  will  do.  In  Chicago  we  use  chymogen  in 
amounts  of  one  dram  to  a  quart  of  milk,  put  up  by  Armour  & 
Co. 

(6)  In  order  to  separate  the  curd  from  the  whey  we  filter, 
letting  the  mixture  hang  in  a  cloth  bag  for  an  hour.  During 
this  process  all  the  whey  drips  off  and  the  pure  casein  curd 
remains. 

(c)  This  is  put  through  a  fine  hair  sieve,  the  wire  meshes  of 
which  must  be  finer  than  a  window-screen.  You  understand  if 
the  casein  is  fed  in  large  pieces  it  will  not  exert  its  physiological 
effects,  for  only  a  small  amount  of  it  will  be  exposed  to  the  intes- 
tinal juices  and  to  the  bacteria  and  less  calcium  can  be  efficient. 
The  center  of  the  curd  vnll  be  untouched.  The  success  of  the 
mixture,  then,  depends  upon  a  very  fine  division  of  the  casein. 
It  must  be  put  through  the  sieve  two  or  three  times. 

(d)  To  the  finely  divided  curd  we  add  one  pint  of  buttermilk. 
Buttermilk  supplies  salts,  and  a  baby  must  have  salts  to  live. 
You  ask  why  a  pint  of  whole  milk  or  skimmed  milk  will  not 
suffice.  Whole  milk,  you  remember,  contains  fat,  which  we  are 
glad  to  reduce  in  these  severe  cases.  Whole  milk  and  skimmed 
milk  both  contain  lactose,  which  is  very  fermentable.  Butter- 
milk not  only  has  no  fat,  but  also  has  very  little  lactose,  and 
possibly  even  the  lactic  acid  may  be  of  aid. 

(e)  Enough  water  is  added  to  make  one  quart.  The  mixture 
is  boiled,  stirred  with  a  cutting  motion  to  prevent  the  reforma- 
tion of  large  curds,  and  divided  into  bottles.  Upon  offering 
them  to  the  baby,  these  bottles  must  not  be  heated  above  body 
temperature  or  large  curds  again  will  form.  You  see  now  what 
this  mixture  contains: 

(a)  The  casein  of  one  quart  of  milk  plus  that  of  one  pint  of 
buttermilk. 


THE  STATES  OP  DYSPEPSIA  AND   INTOXICATION  221 

(6)  The  whey  of  one  pint  of  buttermilk;  thus  the  whey  has 
been  reduced  to  one-half. 

(c)  Almost  no  lactose. 

Everything  in  this  mixture  speaks  for  alkali  formation — 
speaks  against  acid  formation.  What  a  curious  world!  In  the 
olden  times  we  threw  away  the  curd  and  used  the  whey;  now 
we  throw  away  the  whey  and  use  the  curd.  This  mixture  is 
ideal  to  overcome  the  fermentative  stool,  to  neutralize  the  intes- 
tinal reaction,  and  to  stop  the  diarrhea.  Shall  we  feed  this 
mixture  to  the  baby?  What  an  ideal  mixture  this  is  to  kill  our 
little  patient!  You  look  surprised.  You  have  made  just  the 
same  mistake  as  Finkelstein  and  his  assistants.  Reports  of  pro- 
test came  rapidly  from  all  over  the  world.  Not  long,  hov/ever, 
before  the  error  was  detected.  Finkelstein  and  Meyer  had  made 
the  same  mistake  that  we  have  seen  repeated  time  and  time 
again.  They  focused  too  carefully  upon  the  stool  and  forgot  the 
haby!  True  enough,  the  intestinal  condition  was  cured;  the 
stools  became  alkahne  and  constipated,  but  the  baby  died! 
Gentlemen,  the  baby  died  from  lack  of  carbohydrate!  In  our 
intense  desire  to  treat  the  diarrhea  we  forgot  the  baby.  The  child 
must  have  carbohydrate  to  live,  and  this  baby  was  getting  an 
amount  insufficient  for  life.  Without  going  too  much  into  detail, 
it  was  learned  that  in  albumin  milk  it  is  perfectly  safe  to  give 
at  least  3  percent  carbohydrate.  If  this  is  given  in  the  form  of 
non-fermentable  carbohydrate,  such  as  dextrin-maltose  prepar- 
ations, no  harm  will  result ;  so  in  making  albumin  milk,  never 
commit  the  fatal  error  of  omitting  3  percent  carbohydrate.  In 
offering  albumin  milk,  instruct  the  mother  to  use  a  nipple  with 
a  large  hole,  as  some  of  the  casein  curds  may  stick  in  a  small  one. 
You  may  also  add  a  little  saccharine  for  sweetening,  for  when 
the  child  gets  stronger,  he  may  object  to  the  taste  of  the  butter- 
milk. 

In  offering  the  baby  breast  milk  or  albumin  milk,  shall  we 
give  a  full  bottle?  Gentlemen,  to  do  so  means  death.  Even  if 
a  wet-nurse  be  obtainable,  if  we,  thinking  that  breast  milk  is  an 
ideal  food,  recklessly  allow  the  child  to  nurse,  we  probably  shall 
lose  him  in  a  few  hours.  With  such  an  intense  degree  of  fermen- 
tation existing  in  the  intestine,  the  large  amount  of  sugar  in 


222 


INFANT  FEEDING    (CHICAGO  METHODS) 


breast  milk,  even  though  it  be  in  the  healing  breast-milk  whey, 
may  ferment  and  increase  the  daniage. 

In  all  cases  our  technic  must  be  extremely  rigid  and  exact. 

1.  Keeping  up  the  same  general  treatment  of  the  first  day, 
stimulation  and  fluids  in  the  form  of  tea,  we  offer  ten  feedings 
of  about  Yi  ounce  each  of  food. 

2.  The  next  day  we  increase  to  ten  feedings  of  3^  ounce. 

3.  The  following  day  we  may  increase  to  ten  feedings  of 
1  ounce,  then  to  1}^  or  13^  ounces.  Here  we  wait  and  note  the 
reaction  of  our  weight  curve  (Fig.  17): 


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We  hold  the  food  perfectly  constant  at  10  x  IJ/^,  independeni 
of  the  stools,  until  the  weight  curve  has  straightened  out.  If 
the  weight  curve  still  sinks;  if  the  diarrhea  continues,  undei 
no  circumstances  make  any  change  in  the  food.  The  danger  of 
a  change  is  greater  than  the  danger  of  leaving  it  as  it  is.  When, 
however,  the  weight  curve  has  become  horizontal,  we  continue 
to  increase  gradually  to  the  maximum  quantity;  that  is,  about 
three  ounces  of  the  mixture  for  every  pound  of  the  baby's  weight. 
Then  we  cautiously  increase  the  carbohydrate  to  5  percent. 
After  a  few  weeks  we  return  to  an  ordinary  milk  mixture.     It 


THE   STATES   OF  DYSPEPSIA   AND   INTOXICATION  223 

is  7iot  good  policy  at  any  time  to  make  any  change  while  the  baby 
is  gaining. 

I  have  gone  into  such  detail,  gentlemen,  not  because  I  want 
you  to  remember  the  technic  exactly  of  making  albumin  milk, 
but  because  I  want  you  to  remember  the  principles.  If  you 
have  these  principles,  then,  no  matter  where  you  are  or  what 
means  are  at  your  disposal,  simply  make  up  a  combinal^ion  of 
high  protein,  low  whey,  and  non-fermentable  carbohydrate. 
Never  commence  with  large  doses,  but,  following  a  hunger 
period,  guided  by  your  weight  curve,  offer  gradually  increasing 
amounts. 

These  principles  you  can  apply  to  your  older  children — chil- 
dren of  one  to  three  years  of  age : 

1.  Hunger  with  tea  and  fluids  for  the  first  day. 

2.  Reduce  the  whey  by  removing  milk  or  diluting  it  to  one- 
third  or  one-half. 

3.  Increase  the  protein  by  giving  egg,  scraped  meat,  cottage 
cheese,  and  curds  of  milk. 

4.  Give  non-fermentable  carbohydrates,  zwieback,  mashed 
potato  and  cereals,  such  as  corn-starch.  Cream  of  Wheat,  and 
arrowroot. 

5.  Supply  salts  best  as  vegetable  purees. 

Don't  forget  the  hunger  period ;  don't  forget  fluids,  and,  above 
all  things,  in  the  beginning  of  the  treatment,  don't  forget  the 
tiny  doses  of  food. 

Gentlemen,  if  you  are  thoroughly  conversant  with  these 
principles,  no  matter  where  you  are,  no  matter  how  primitive 
the  home,  you  will  always  be  completely  master  of  the  situation. 


LECTURE  VI 
DECOMPOSITION 

Gentlemen,  in  the  previous  lectures  we  discussed  three  types 
of  nutritional  disturbance.  You  remember  it  was  Finkelstein 
who,  for  the  first  time,  clearly  and  emphatically  laid  importance 
upon  factors  of  nutrition  and  food,  in  the  production  of  what  we 
previously  had  called  "the  diarrheal  diseases  of  infants."  That 
many  of  his  first  explanations  were  incomplete;  that  many  of 
his  views  again  will  be  amplified,  there  can  be  no  doubt.  But 
his  service  has  been  immeasurable.  In  the  lectures  on  dis- 
turbed balance,  dyspepsia,  and  intoxication  we  described  the 
clinical  pictures  as  he  saw  them.  Today  we  concern  ourselves 
with  the  last  of  the  four,  the  subject  of  decomposition.  You 
gentlemen  have  known  this  condition  as  atrophy,  marasmus, 
or  malnutrition.  It  is  familiar  to  you  all.  Finkelstein,  however, 
did  not  think  that  these  terms  described  accurately  the  compli- 
cated processes  being  evolved  in  the  child's  body,  and  so  sug- 
gested a  term  of  his  own.  Names,  of  course,  are  immaterial. 
If  you  prefer  the  older  terms,  well  and  good.  The  essential, 
however,  is  that  you  understand  the  changes  taking  place  in 
the  child.  There  is  an  actual  disintegration  of  body  substance, 
Finkelstein  thought  the  usual  terms  misleading  and  so  spoke  of 
decomposition,  which  in  German  means  destruction. 

It  is  hardly  necessary  to  describe  the  picture.  Doubtless  you 
have  seen  it  often.  A  tiny,  undernourished  infant,  weight  far 
below  normal,  lies  restless  and  crying  in  his  bed  or  in  his  mother's 
arms.  Simultaneously  one  notices  the  pallid,  blue,  wrinkled, 
tissue-paper-like,  fat-free  skin,  and  the  whole  bony  skeleton  that 
seems  to  protrude  through  it.  The  face  is  that  of  a  tired  old 
man.  The  large,  deep-seated  eyes  move  restlessly  about,  then 
fix  upon  you  with  an  uncanny  stare.  The  large  mouth,  with  its 
thin  lips  opened  wide  in  a  never-ceasing  fretful  cry,  is  in  striking 

disproportion  to  the  small,  weazened  face,  or  is  hidden  com- 

224 


DECOMPOSITION 


225 


pletely  by  the  fists  which  the  child  chews  greedily  in  a  vain 
attempt  to  relieve  his  pitiful  hunger.  The  peevish  tones  reveal 
perpetual  misery.  The  emaciated  skin  of  the  thorax  reveals  the 
bony  framework  in  all  its  detail,  and  the  thin  covering  of  the 
abdomen  cannot  conceal  the  outlines  and  movements  of  the 


Fig.  18. 


Fig.  19 


viscera.     On  the  extremities  the  skin  hangs  in  large  folds  right 
over  the  bones  (Figs.  18  and  19). 

In  sharp  contrast  to  intoxication,   consciousness  is  undis- 
turbed.    If  anything,  it  is  excited.     You  remember  how  the 
child  with  intoxication  lies  drowsily,  eyes  fixed  apathetically  on 
15 


226  INFANT  FEEDING    (CHICAGO  METHODS) 

one  corner  of  the  room,  arouses  himself  with  a  short  cry,  and 
again  lapses  into  semi-consciousness.  This  child  is  on  the  alert, 
cries  pitifully,  incessantly,  and  never  seems  to  sleep.  You 
remember  the  child  with  the  intoxication  had  rapid,  tireless 
respiration.  This  child  has  the  slow,  feeble,  irregular  type. 
In  intoxication  the  pulse  is  rapid.  In  decomposition  the  pulse 
is  slow  and  weak.  Normally  in  an  infant  the  pulse  ranges  around 
120.  Here  it  may  be  80  or  below.  In  intoxication  the  temper- 
ature usually  is  elevated.  In  decomposition  it  is  subnormal — 
the  more  subnormal,  the  worse  the  disturbance.  In  contrast 
to  the  albuminuria,  glycosuria,  and  casts  of  intoxication,  the 
urine  of  this  child  is  negative.  Intoxication  suggests  acute 
poisoning;  decomposition,  chronic  collapse. 

Symptoms  from  the  gastro-intestinal  tract  vary  with  the  food. 
Vomiting  is  not  unusual.  Stools,  however,  depend  to  a  large 
extent  upon  the  diet.  When  this  is  large,  particularly  if  high 
in  carbohydrate,  intestinal  fermentation  becomes  active,  with 
resulting  diarrhea.  This  is  very  easy  to  understand  when  we 
consider  that  the  intestinal  tract  suffers  in  its  general  nutrition 
as  much  as  does  every  other  organ  of  the  body.  It  is  perfectly 
rational,  then,  to  assume  that  the  functionally  injured  intes- 
tinal cells  of  the  upper  digestive  tract  do  not  suppress  bacterial 
growth  as  they  do  in  the  normal  infant.  Consequently  any 
improper  combination  of  food,  especially  mixtures  rich  in  whey 
and  carbohydrate,  stir  these  bacteria  to  growth,  and  in  the 
resulting  fermentation  are  formed  the  irritating  acid  products 
which  lead  to  dyspepsia  and  intoxication.  In  such  a  condition, 
if  much  fat  is  fed,  it  wall  be  carried  out  in  the  stool.  We  do 
not  mean  to  be  too  dogmatic.  It  is  perfectly  reasonable  and 
logical,  and  there  is  also  good  evidence  to  show  that  the  digestive 
ferments  are  not  very  active,  and  we  can  readily  understand  the 
appearance  of  fat  in  the  stools,  due  to  its  improper  digestion 
and  assimilation.  We  believe,  however,  that  in  the  majority 
of  cases  fat  appears  passively,  being  secondary  to  the  primary 
fermentation  of  the  carbohydrate. 

On  the  other  hand,  if  the  restricted  diet  is  high  in  protein, 
low  in  carbohydrate  and  whey,  the  stool  becomes  alkaline  and 
hard.  Now  less  undigested  fat  appears.  This  observation  again 
supports  the  premise  that  fat  is  really  the  secondary  factor. 


DECOMPOSITION  227 

Again,  the  smaller  the  diet,  the  less  likely  will  the  stool  be  diarrheal. 
Perhaps  no  better  illustration  can  be  afforded  of  the  danger  of 
being  guided  in  treatment  by  the  condition  of  the  stools.  Many 
of  these  babies  go  down  and  die  in  collapse,  with  typical  consti- 
pation. No  greater  or  more  terrible  mistake  can  be  made  than 
of  focusing  all  one's  attention  upon  the  character  of  the  stool 
(treating  the  stool  so  as  to  change  it  from  a  diarrheal  to  a  con- 
stipated type)  and  forgetting  the  baby  in  the  meantime:  allow- 
ing the  baby  to  go  down  and  die  in  the  collapse  of  hunger.  This 
danger  can  be  avoided  if  one  remembers  what  we  have  repeated 
again  and  again,  that  the  stools  are  simply  indications  of 
what  has  been  put  into  the  intestinal  tract,  of  the  way  that  food 
has  been  handled,  and  are  only  a  tiny  guide  to  us — simply  a 
symptom  of  scarcely  more  importance  as  an  absolute  indication 
for  therapy  than  is  the  condition  of  the  skin,  than  the  condition 
of  the  baby's  heart  and  pulse,  than  the  condition  of  the  baby's 
breathing.  They  constitute  simply  one  of  the  many  important 
symptoms  of  the  condition.  As  the  weakened  pulse  points  to 
the  failing  circulation,  so  do  the  abnormal  stools  point  to  an 
inefficient  digestive  tract.  This  latter — not  the  stool — is  one  of 
the  objects  of  our  therapy. 

In  these  conditions  we  have  dwelt  upon  the  fundamental 
importance  of  the  weight  curve  and  the  food  reactions  (Fig.  20). 
•  If  at  A,  the  child  being  in  a  state  of  decomposition,  and  hav- 
ing lost  weight  for  months,  we  give  a  bottle  adapted  to  a  normal 
child,  he  loses  steadily  three  to  five  ounces  a  day,  and  dies  not 
infrequently  with  symptoms  of  intoxication.  On  the  other 
hand,  withdrawal  of  food  for  twenty-four  hours  produces  a  sharp 
drop  in  weight,  the  child  dying  in  acute  collapse. 

Gentlemen,  no  more  terrible  mistakes  are  made  than  allowing 
children  in  this  condition  to  hunger.  They  are  so  susceptible 
to  all  influences  that  a  period  of  hunger  of  twenty-four  hoiu-s, 
which  scarcely  would  be  noticed  by  a  normal  baby  other  than 
by  his  loud  protests,  results  in  rapid  death. 

In  addition  to  the  above  clinical  symptoms  the  child  shows 
great  change  in  reactions  to  external  influences.  He  is  particu- 
larly susceptible  to  heat  and  to  cold.  He  is  susceptible  to  all 
forms  of  violence,  readily  injured  by  improper  nursing  and  care, 
particularly  likely  to  be  attacked  and  carried  away  by  the  infec- 


228 


INFANT  FEEDING   (CHICAGO  METHODS) 


tious  diseases.  Ludwig  F.  Meyer  says  aptly  that  these  children 
sicken  from  causes  of  nutrition  and  die  from  infection.  Fatal 
infections  frequently  are  overlooked,  even  by  the  most  experi- 
enced, because  the  child  is  so  weakened  in  his  reactions  that  the 
most  virulent  infections  may  give  no  cHnical  signs.  The  baby 
is  too  weak  to  react  with  temperature,  too  weak  to  show  acceler- 
ation of  the  pulse  or  of  the  breathing,  and  only  postmortem 
examination  reveals  how  frequently  our  httle  patients  have  been 
carried  away  with  terminal  pneumonias. 


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Often  we  find  masked  types  of  decomposition.  Upon  hasty 
clinical  examination,  we  may  think  our  little  patient  is  only  in 
a  state  of  dyspepsia  or  disturbed  balance.  We  become  suspi- 
cious, however,  on  learning  of  a  previously  irregular  weight 
curve,  and  noting  deficiency  of  fat  in  the  subcutaneous  tissues 
and  skin  of  muddy  color.  Our  opinion  unll  be  confirmed  when, 
upon  treating  this  child  for  a  dyspepsia,  withdrawal  of  food  pro- 
duces not  the  usual  slight  reaction  of  the  weight  curve,  but  a 


DECOMPOSITION 


229 


sharp,  severe  drop  of  many  ounces,  associated  with  subnormal 
temperature  (Fig.  21). 


Days. 

. 

J 

; 

11 

a 

10  lb. 

12  oz, 

8 

4 

9  lb. 

100 
99 
98 
97 
96 

_— • 

1 — ~ 

\ 

\ 

"H 

EXi 

... 

I 

V 

\ 

> 

\ 

**> 

^-^ 

\ 

Fig.  21. 

Gentlemen,  whenever  you  find  a  child  upon  withdrawal  of 
food  reacting  with  symptoms  of  collapse  and  subnormal  tem- 
perature, no  matter  how  slight  you  considered  the  disturbance, 
beware  of  one  of  these  masked  types  of  decomposition.  Remem- 
ber that  that  child  is  particularly  susceptible  to  external  influ- 
ences— to  hunger,  to  heat,  to  cold,  to  infections,  to  poor  nurs- 
ing, to  improper  food^ — and  look  upon  him  as  a  very  sick  baby. 

Metabolism. — Having  studied  the  clinical  picture  carefully, 
we  now  must  investigate  the  causes.  Don't  misunderstand  me, 
gentlemen;  it  has  long  been  known  that  this  picture  can  be  pro- 
duced by  tuberculosis,  syphilis,  wasting  diseases,  and  other  con- 
ditions; but  it  remained  for  Finkelstein  to  show  that  a  great, 
great  number  of  these  cases — cases  in  which  the  etiology  pre- 
viously had  been  mysterious  or  unknown — was  based  upon  and 
resulted  from  the  same  fundamental  errors  in  nutrition  of  which 
we  have  spoken  so  frequently.  For  the  first  time  we  see  in 
careful  clinical  examination,  this  condition  also  studied  from  the 
broad  viewpoint  of  nutritional  disease.  Such  a  child,  when 
placed  upon  a  metabolism  bed,  shows  a  sharp  contrast  to  dys- 
pepsia or  disturbed  balance,  for  he  suffers  actual  loss  of  protein 
from  the  body,  the  body  losing  more  protein  than  is  taken  in. 


230  INFANT  FEEDING    (CHICAGO   METHODS) 

The  same  holds  true  for  mineral  matter;  more  salts  are  lost  than 
are  contained  in  the  food.  Indeed,  much  of  the  clinical  picture 
may  be  simulated  by  mineral  hunger.  Such  investigations  are 
very  difficult,  are  few  in  number,  but  are  of  tremendous  value. 
It  was  due  to  this  conception,  to  this  idea,  that  actual  destruc- 
tion was  taking  place  that  Finkelstein  changed  the  term  from 
atrophy  to  decomposition. 

The  fat  metabolism  depends  upon  the  way  fat  is  administered. 
If  it  is  given  in  a  mixture  rich  in  carbohydrate  and  whey,  the 
fat  is  lost  in  the  resulting  diarrhea.  If  a  reasonable  quantity''  is 
given  in  a  mixture  high  in  protein,  low  in  carbohydrate  and  whey, 
the  fat  is  well  assimilated. 

As  regards  carbohydrates,  the  body  itself  seems  to  need  and 
use  them  well.  The  great  difficulty,  however,  is  to  get  them 
into  the  body,  for  with  the  weakened  condition  of  the  upper 
intestine  permitting  bacteria  to  flourish,  carbohydrates,  unless 
given  very  carefully,  are  apt  to  ferment  and  cause  diarrhea,  with 
pictures  varying  from  the  slightest  dyspepsia  to  the  severest 
intoxication. 

Diagnosis. — The  diagnosis  is  easy.  A  freshman  medical 
student,  a  novice,  a  beginner,  can  recognize  such  a  picture  at  a 
glance.  It  makes  absolutely  no  difference  what  name  we  give, 
the  clinical  picture  is  there ;  and  it  remains  for  us  as  medical  men 
not  to  be  content  with  a  mere  diagnosis,  but  to  insist  upon  a 
diagnosis  of  the  cause.  We  have  spoken  of  tuberculosis,  syphilis, 
and  wasting  disease;  these  are  well  known ;  but  of  new  factors 
from  the  viewpoint  of  nutrition  we  are  learning  more  and  more. 

1.  We  have  learned  that  this  condition  never  comes  in  the 
midst  of  health.  The  child  must  have  been  sick  for  weeks  or 
months,  with  a  history  of  ailing,  of  digestive  disturbance,  and 
of  not  thriving. 

2.  We  have  learned  the  importance  of  age.  The  younger  the 
child,  the  more  susceptible  he  is. 

3.  We  have  learned  the  importance  of  diarrheas,  not  only 
those  from  improper  feeding,  the  dyspepsias,  but  also  those 
resulting  from  true  pathogenic  bacterial  infection.  In  each  of 
these  attacks  the  child  probably  loses  a  little  mineral  matter, 
and  if  the  diarrhea  is  not  handled  properly,  the  loss  eventually 
may  be  so  great  as  to  bring  on  decomposition. 


DECOMPOSITION 


231 


4.  We  have  learned  that  long-continued  undernourishment 
is  an  important  factor,  the  baby  not  getting  for  a  sufficient  time 
a  great  enough  total  quantity  of  food. 

5.  Hunger  is  a  tremendous  factor,  particularly  hunger  applied 
too  long  to  a  sick  child  (Fig.. 22). 


I 

2 

5 

I 

9  lb 
12  oz 

8    02 

4  oz 

\ 

\ 

\ 

\ 

9 

i 

i 

\ 

\ 

8  lb 

\ 

\ 

Fig.  22. 


You  remember  in  intoxication  when  the  weight  curve  was  drop- 
ping rapidly,  if  we  removed  food  at  A  for  twenty-four  hours 
the  drop  of  weight  ceased  and  the  curve  straightened  out.  If 
at  the  end  of  twenty-four  hours,  at  B  we  had  not  started  to 
feed  that  baby  perfectly  independent  of  the  number  or  condition 
or  appearance  of  the  stools,  if  instead  of  feeding  him  we  had 
prolonged  the  hunger  period,  guided  only  by  the  condition  of 
the  stools,  the  weight  curve  would  have  swung  down,  taken 
another  sharp  drop,  and  we  would  have  been  responsible  for  the 
additional  calamity  of  decomposition. 

6.  Important  as  is  absolute  hunger,  partial  hunger  is  perhaps 
even  a  more  frequent  cause.  By  partial  hunger  I  mean  one- 
sided feeding,  such  as  feeding  with  barley  water  or  condensed 
milk.  Due  to  the  fault  of  the  physician  or  the  carelessness  of 
the  mother,  children  are  kept  for  days  on  a  diet  of  barley  water. 
This,  as  you  know,  is  largely  carbohydrate,  and  after  four,  five, 
or  six  days,  the  child  suffering  in  the  meantime  from  insufficiency 


232  INFANT   FEEDING    (CHICAGO   METHODS) 

of  protein,  salts,  and  fat,  decomposition  develops.  This  type 
was  the  one  that  Czerny  described  as  starch  injury.  Condensed 
milk  perhaps  is  the  most  frequent  cause.  It  is  very  high  in  sugar, 
low  in  other  elements,  as  protein  and  salts.  You  remember  in 
our  second  lecture  we  spoke  about  the  property  of  sugar  to  bind 
water  in  the  tissues.  Due  to  the  high  sugar  of  condensed  milk, 
a  great  deal  of  water  is  retained  in  the  tissues  of  these  children. 
They  gain  for  some  weeks,  and  the  doctor  and  mother  are 
delighted,  because  they  think  the  baby  is  doing  so  well.  As  a 
matter  of  fact,  however,  the  baby  is  starving,  his  tissues  are 
being  filled  with  water,  and  his  body-cells  are  dying  from  lack 
of  protein  and  salt.  Only  the  severe  reaction  following  a  slight 
infection,  following  a  little  exposure  to  heat  or  a  slight  error  in 
diet  (such  as  feeding  a  little  too  much  or  letting  him  hunger 
too  long),  shows  that  we  are  handhng  a  child  who  really  is  in 
the  stage  of  decomposition.  Too  long  exclusive  feeding  with 
breast  milk  belongs  to  this  class.  This  sounds  like  heresy,  gen- 
tlemen ;  but  nevertheless  it  is  true.  This  is  no  infrequent  factor. 
As  you  remember,  breast  milk  is  very  low  in  protein  and  very 
low  in  mineral  matter.  After  a  child  is  nine  months  or  more 
of  age  the  demands  of  his  body  are  greater  than  those  answered 
by  the  breast.  Kept  too  long  exclusively  upon  this  food,  with- 
out the  addition  of  other  substances  to  cover  these  wants,  or 
without  an  enormous  supply  of  breast  milk,  the  body-cells  suffer 
from  lack  of  protein  and  salts,  and  the  child  gradually  develops 
decomposition. 

7.  The  most  frequent  factor  of  all  is  probably  the  fault  of  the 
physician,  the  one  for  which  you  largely  are  to  blame,- — I  don't 
mean  you  personally;  I  mean  you,  me,  all  physicians, — namely, 
the  improper  treatment  of  mild  dyspepsias.  The  development 
is  as  follows:  The  child  gets  a  shght  dyspepsia;  the  physician, 
not  recognizing  the  food  nature  of  the  disturbance,  cleans  him 
out  with  calomel  and  castor  oil;  gives  him  a  little  paregoric  to 
check  the  bowels,  and  makes  no  change  in  the  food.  Repetition 
occurs  in  perhaps  two  or  three  weeks.  Again  the  child  is  cleaned 
out,  again  is  he  subjected  to  the  irritating  effect  of  calomel,  and 
again  the  bowels  are  drugged  with  paregoric;  but  the  food  is 
unchanged.  Maybe  the  factor  of  hunger  is  introduced.  A 
recurrence  of  diarrhea  leads  to  the  same  treatment.     Now  the 


DECOMPOSITION  233 

physician  says:  "We  certainly  will  give  these  bowels  a  rest. 
We  are  going  to  let  this  baby  hunger  a  good  long  time."  No 
factor,  gentlemen,  is  more  important  in  bringing  these  children 
to  this  condition  than  is  the  frequent  combination  of  improper 
therapy  of  dyspepsia  plus  the  improper  use  of  hunger.  Remem- 
ber, gentlemen,  the  longer  the  hunger,  the  greater  the  danger. 
Remember,  the  more  frequently  repeated  the  hunger,  the  greater 
the  danger;  and  remember,  the  closer  together  the  hunger 
periods,  the  greater  the  danger.  This  combination  of  improper 
treatment  of  dyspepsia  plus  the  improper  use  of  hunger  periods 
is  the  most  important  of  all  the  nutritional  factors  in  producing 
decomposition. 

Besides  the  above  errors  in  nutritional  technic,  we  must  never 
forget  that  the  same  influences  are  effective  that  were  concerned 
in  the  production  of  dyspepsia  and  intoxication,  influences  which 
are  independent  of  our  skill,  and  for  which  we  are  not  to  blame; 
namely,  constitution,  infection,  and  improper  care.  A  baby 
with  a  weak  constitution,  a  baby  who  repeatedly  has  had  infec- 
tions, a  baby  who  is  improperly  cared  for,  is  far  more  susceptible 
to  a  nutritional  error  than  is  a  healthy  strong  child. 

Treatment. — Gentlemen,  let  me  urge  upon  you  that  the  most 
important  treatment  by  far  is  prophylaxis.  If  we  handle  dys- 
pepsias properly;  if  we  realize  the  importance  of  the  state  of 
disturbed  balance;  if  we  see  that  the  well  baby  is  properly 
nursed  and  cared  for,  properly  dressed  and  properly  fed,  the 
number  of  cases  of  decomposition  arising  from  nutritional 
sources  will  be  very  few  indeed. 

Once  developed,  however,  the  condition  is  difficult  to  treat, 
and  requires  careful,  definite  routine.  Only  upon  two  foods  can 
we  rely.  Just  as  in  intoxication,  we  have  absolute  confidence 
only  in  breast  milk  or  albumin  milk. 

During  the  first  day,  if  a  bad  diarrhea  is  present,  the  child 
may  hunger  six,  to  at  the  very  most  twelve,  hours;  never  under 
any  circumstances  longer.  Preferably,  he  should  miss  only  one 
or  two  bottles,  and  none  if  the  stools  are  few  in  number.  During 
this  period  the  general  treatment  is  that  of  intoxication;  that 
is,  the  use  of  stimulants,  the  use  of  water  and  tea,  the  use  of  a 
Uttle  salt. 

Following  the  hunger  period,  or  if  no  diarrhea  be  present  at 


234 


INFANT   FEEDING    (CHICAGO   METHODS) 


once,  we  start  food.  The  first  day  we  offer  ten  feedings,  with  a 
total  in  twenty-four  hours  of  ten  ounces.  Gradually  we  increase, 
adding  two  to  three  ounces  to  the  twenty-four-hour  total  every 
other  day.  Our  maximum  with  albumin  milk  is  three  ounces 
for  each  pound  of  body  weight;  that  is,  a  baby  weighing  seven 
pounds  shall  get  a  total  of  21  ounces,  a  baby  of  nine  pounds  a 
total  of  27  ounces.  During  this  increase  our  guide  is  solely  the 
weight  curve.  Gentlemen,  let  me  impress  upon  you  that  no 
graver  mistakes  can  be  made  than  letting  the  condition  of  the 
stools  influence  your  treatment.  We  are  interested  in  saving 
the  baby.  The  baby  is  infinitely  more  important  than  his 
gastro-intestinal  canal.  If  to  save  the  baby  it  becomes  neces- 
sary to  neglect  all  symptoms  of  impaired  digestion,  we  must  do 
so.  The  gastro-intestinal  tract  is  simply  a  means  of  introducing 
nourishment.  We  absolutely  must  give  food.  If  we  let  this  one 
symptom,  the  stool,  sway  us  from  our  course,  though  we  correct 
the  condition  of  the  stool,  we  frequently  lose  our  patient.  Our 
guide  to  increase  shall  be  the  weight  curve.  To  illustrate  (Fig.  23) : 


Tfeeks 

, 

. 

Sa 

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i 

t 

^ 

i 

( 

10  Xb 

\ 

">s 

8    0! 

4  oi 

9  11> 
U  Oi 
8  Oi 
4  Oi 

8  lb 

12  o: 

S 

s 

V 

s 

N, 

H 

s 

\ 

O 

\ 

y 

\ 

^ 

/ 

S 

^ 

^ 

^ 

, 

^ 

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. 

Fig.  23. 


The  baby  has  been  sick  for  weeks,  the  curve  constantly  com- 
ing downward.  At  A  he  is  in  the  state  of  decomposition.  We 
allow  him  to  hunger  or  offer  small  quantities  of  food,  a  total  in 
twenty-four  hours  of  ten  ounces.  Due  to  the  hunger  or  due  to 
the  small  quantities  of  food  he  continues  to  lose  slightly.     We 


DECOMPOSITION  235 

make  no  change  until  at  B  his  curve  has  straightened  out.  A 
continuation  downward  at  C  shows  that  the  destructive  process 
is  continuing;  under  these  circumstances  we  are  in  no  condition 
to  increase  the  diet,  nor  to  change  nor  to  withdraw  it.  If  we  wish 
to  save  the  baby,  we  must  hold  the  quantity  constant  and  steady, 
independent  of  the  stools,  until  the  curve  has  straightened  and 
shown  that  destruction  is  ceasing  and  that  the  baby  now  is  in  a 
position  to  assimilate  nourishment.  This  is  the  time  to  start 
a  gradual,  cautious  increase  according  to  the  schedule  just  given. 
If  the  baby  is  breast  fed,  under  no  circumstances  put  him  to  the 
breast  the  first  few  days.  The  mother  must  express  the  milk 
from  her  breasts  and  give  these  quantities  exacthj  from  a  bottle 
or  medicine-dropper.  When  the  curve  finally  has  straightened 
out, — a  matter  of  a  few  days, — we  sigh  with  rehef ,  for  the  battle 
is  won;  and  now,  after  the  child  has  gained  sUghtly,  it  is  safe 
to  put  him  again  gradually  to  the  breast. 

In  the  last  lecture  I  gave  in  detail  the  technic  of  making  albu- 
min milk.  I  wanted  you  to  know  the  original  process,  so  as  to 
emphasize  the  principles  of  the  mixture.  You  remember  they 
were  low  whey  and  low  carbohydrate  to  reduce  the  factors  caus- 
ing fermentation;  high  protein  to  increase  the  factors  causing 
alkahnity  and  overcoming  fermentation.  Today  I  want  to  give 
you  a  simpler  technic  quoted  by  Langstein  and  Meyer,  one 
which  you  may  use  in  the  humble  home,  where  ignorance  of  the 
mother  or  lack  of  facilities  renders  impossible  the  more  compli- 
cated mixture. 

One  takes  one  quart  of  buttermilk  and  one  quart  of  water, 
mixes  them  well,  lets  them  boil  a  few  minutes,  and  allows  them 
to  stand  for  at  least  half  an  hour.  During  this  period  the  casein 
curd  settles  to  the  bottom  and  the  clear  whey-water  mixture 
rises  to  the  top.  You  see,  by  the  addition  of  water  we  have 
diluted  the  whey  one-half.  Without  disturbing  the  casein  curd 
lying  below,  we  pour  into  another  jar  as  much  whey  as  possible. 
This  separates  curd  from  whey.  In  this  process  we  boiled  the 
milk.  In  the  original  we  used  it  raw.  If  we  had  boiled  it  in  the 
original  technic  the  curds  would  have  been  too  fine  to  be  separated 
from  the  whey,  being  able  to  pass  during  the  filtration  through 
the  meshes  of  the  muslin  bag.  To  the  casein  curd  we  add  four 
ounces  of  boiled  cream.     This  is  done  because  in  the  original 


236 


INFANT   FEEDING    (CHICAGO   METHODS) 


mixture,  during  precipitation  of  the  casein,  considerable  fat  is 
ensnared  in  its  meshes,  the  fat  content  of  albumin  milk  be- 
ing 2  to  3  percent.  Accordingly,  we  add  cream  to  this  mixture. 
We  then  add  the  usual  3  percent  of  a  dextrin-maltose.  Not 
having  "dextri-maltose,"  we  can  use  foods  of  somewhat  similar 
nature,  such  as  Melhn's  Food  or  Horlick's  Malt  Food.  Our 
mixture  now  contains  high  protein,  a  certain  amount  of  fat,  a 
certain  amount  of  carbohydrate  in  a  non-fermentable  form,  and 
to  add  salts  we  fill  up  to  a  total  of  one  quart  with  the  original 
water^whey  mixture  in  our  second  jar.  You  see  in  this  process 
we  have  reduced  the  whey  to  one-half.  In  cases  where  the  child 
does  not  take  albumin  milk  well  it  can  be  sweetened  with  a 
little  saccharine. 

And  now,  gentlemen,  before  concluding,  let  me  call  your 
attention  to  a  most  fascinating  study,  one  to  which  this  treat- 
ment with  albumin  milk  has  directed  us  (Fig.  24). 


"■ 

n 

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1 

. 

i 

I 

r 

1 

^— 

> 

10  lb 

e  oa 
9  lb 

\ 

\ 

/ 

s 

/ 

\ 

/ 

s 

y 

r 

N 

/ 

8  lb 

s 

s 

I 

/ 

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^1 

> 

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^ 

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f 

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f 

5 

0/ 

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9 

9 

0/ 

) 

_J 

_J 

J 

_ 

Fig.  24. 


•  At  A  the  weight  curve  has  straightened  out,  the  destructive 
process  has  ceased,  the  battle  has  been  won,  and  the  child  is 
getting  the  total  prescribed  amount  of  albumin  milk,  but  he 
is  not  gaining.  We  are  giving  the  maximum  quantity,  namely, 
three  ounces  for  each  pound  of  body  weight,  but  the  weight 
curve  is  stationary.  Here  a  very  interesting  study  commences. 
Our  first  idea  that  sugar  alone  is  dangerous  and  harmful  makes 
us  very  careful  about  increasing  the  carbohydrate.  We  cxiu- 
tiously  increase  to  5  percent.  In  some  cases  the  weight  curve 
makes  a  sharp  ascent;   in  others  it  remains  stationary.     After 


DECOMPOSITION 


237 


a  few  days,  in  the  latter  case,  we  feel  our  way  again  and  increase 
to  7  percent.  Usually  the  curve  takes  a  sharp  rise  and  the  im- 
provement continues,  but  it  may  remain  absolutely  horizontal. 
Again,  with  extreme  care,  and  under  no  circumstances  if  the  curve 
shows  a  tendency  to  fall,  we  increase  to  9  percent,  and  almost 
invariably  with  9  percent  the  child  will  gain.  With  7  percent 
or  9  percent  the  stools  may  become  dyspeptic,  but  employing 
albumin  milk,  we  overlook  them.  Under  no  circumstances  use 
such  high  carbohydrate  with  any  food  other  than  albumin  milk. 


Fig.  25. 


Here  is  the  baby  we  just  showed  as  a  case  of  severe  decompo- 
sition. He  entered  our  hospital  wards  aged  four  months  and 
weighing  six  pounds.  On  albumin  milk  with  3  percent  dextri- 
maltose  he  showed  no  reaction  for  three  days.  An  increase  to 
5  percent  resulted  in  no  further  gain.  Three  days  later,  however, 
a  further  increase  to  7  percent  was  followed  by  a  rapid  increase 
in  weight  and  marked  improvement  in  his  general  condition. 
This  photograph,  taken  at  the  age  of  five  months,  just  four  weeks 
later,  shows  him  weighing  nine  pounds  four  ounces.  Just  com- 
pare this  to  his  previous  condition,  and  you  will  notice  the  rapid 
response  to  high  carbohydrate  feeding,  a  gain  of  3  pounds  4 
ounces  in  a  month  (Figs.  18,  19,  25). 

This  interesting  cUnical  study  gives  an  insight  into  some  of 


238  INFANT   FEEDING    (CHICAGO   METHODS) 

the  processes  taking  place  in  the  child's  body.  It  shows  that 
this  child,  to  thrive,  needs  more  carbohydrate  than  does  a  nor- 
mal one ;  and  when  we  stop  to  think,  this  is  not  unreasonable, 
because  he  is  so  handicapped  that  he  probably  needs  more  energy 
than  does  the  healthy  baby  to  carry  him  along.  Our  problem 
has  become  clear.  We  must  convey  food  to  this  child's  tissues. 
In  some  cases  the  deficiency  is  one  of  protein  and  mineral  matter. 
In  the  majority,  however,  high  carbohydrate  also  must  be  con- 
veyed. We  have  before  us  the  problem  of  sending  high  carbo- 
hydrate into  the  baby's  body;  of  getting  it  through  the  intes- 
tinal wall  before  the  hungering  bacteria  lying  in  wait  in  the 
intestine,  can  ferment  it  to  the  irritating  acid  products;  with- 
out its  carrying  the  patient  to  death  from  intoxication  before  it 
reaches  the  body-cells  craving  it.  Albumin  milk  has  solved  this 
problem  in  a  mysterious,  unexplainable  way.  It  was  never 
devised  for  this  purpose,  but  it  is  just  as  effective,  nevertheless. 
If  we  feed  a  child  with  decomposition  a  concentrated  milk  mix- 
ture containing  high  carbohydrate,  he  rapidly  develops  the 
severest  intoxication.  Whether  the  child's  demands  are  abso- 
lutely specific  for  carbohydrate  or  simply  for  more  energy  may 
be  open  to  argument.  But  even  if  the  latter  is  true,  carbohy- 
drate becomes  the  most  convenient  means  of  supplying  the 
needed  energy.  With  albumin  milk  we  can  feed  carbohydrate 
with  relatively  slight  danger  of  intestinal  comphcation. 

How  albumin  milk  does  this  is  unknown.  We  have  much  to 
learn,  and  perhaps  some  one  T\dll  explain  it;  but  it  is  a  fact, 
nevertheless,  that  albumin  milk  has  become  a  vehicle  for  intro- 
ducing carbohydrate  into  the  baby's  system. 

The  treatment  with  albumin  milk  should  last  four  to  six 
weeks,  and  then  the  baby  is  put  upon  an  ordinary  milk  mixture. 
For  a  few  days  the  stools  will  be  somewhat  loose;  these  can  be 
disregarded.  If  the  baby  has  been  breast  fed,  although  he 
seems  subjectively  better,  gain  in  weight  may  be  very  slow  in- 
deed. This  period  the  older  men  have  called  the  "reparation 
period,"  offering  the  explanation  that  during  these  weeks  the 
child's  tissues  were  reorganized.  This  failure  to  gain  we  now 
believe  due  to  tissue  hunger.  Breast  milk  you  know  is  low  in 
salts  and  in  protein.  The  ideal  food  for  a  normal  baby,  it  is 
not  a  mixture  ideal  for  an  infant  to  recover  severe  losses  of  these 


DECOMPOSITION  239 

elements.  The  addition  to  the  breast  milk  of  small  quantities 
of  a  buttermilk  mixture  sometimes  works  wonders.  This  com- 
bination is  rich  in  protein,  rich  in  mineral  matter — the  very 
substances  in  which  breast  milk  is  deficient.  If  given  in  quan- 
tities of  one-third  to  one-half  of  the  total  amount  of  breast  milk, 
the  child  may  gain  at  a  much  earlier  date  and  the  so-called 
reparation  period  be  avoided. 

Having  mastered  these  processes,  we  are  in  a  position  to  treat 
decomposition  in  an  older  child.  Always  hold  before  you  the 
picture  of  the  technic  with  albumin  milk.  In  the  older  child 
also,  the  period  of  hunger,  if  diarrhea  is  present,  must  be  short, 
and  then  we  start  to  feed.  How  shall  we  make  up  our  diet? 
First,  we  reduce  the  whey  as  much  as  possible,  the  whey  being 
the  element  that  seems  to  aid  fermentation  and  the  formation  of 
irritating  acids.  This  means  that  we  either  can  remove  the  milk 
entirely  from  the  diet  or,  preferably,  dilute  it  to  one-third  or 
one-half  strength.  To  offer  the  child  food  which  will  alkalinize 
the  bowel  and  overcome  fermentative  processes  we  feed  high 
protein,  namely,  scraped  meat,  eggs,  cottage  cheese,  or  even 
ordinary  curds  of  milk.  Custards  are  taken  well  and  provide 
an  easy  method  of  offering  eggs.  To  supply  carbohydrate  in 
non-fermentable  form  we  use  cereals,  such  as  corn-starch,  farina, 
Cream  of  Wheat,  arrowroot,  and  well-boiled  rice.  We  don't 
advise  oatmeal,  because  in  some  cases  this  seems  to  ferment 
easily.  Other  non-fermenting  carbohydrates  are  mashed  Irish 
potatoes  and  the  doubly  baked  bread,  kno^vTi  usually  under  the 
name  of  ''zwieback."  Now  we  have  a  combination  high  in 
protein,  low  in  whey,  containing  non-fermentable  carbohydrates, 
low  only  in  salts.  These  we  supply  in  broths  and  soups  and  by 
vegetables  ground  through  a  very  fine  sieve  in  the  form  of 
purees;  we  supply  a  mixture  high  in  protein  and  in  salts  by 
offering  a  small  quantity  of  buttermilk;  but  remember  the  but- 
termilk contains  all  the  whey  elements,  hence  tends  to  aid  fer- 
mentation, and  therefore  should  be  used  in  small  quantities  and 
handled  carefully. 

Remember,  gentlemen,  that  the  technic  we  use,  however, 
must  be  identical  to  that  employed  with  a  little  baby.  Hunger 
periods  are  short;  the  quantity  of  food,  at  first  small,  is  grad- 
ually increased,  and  above  everything  else  the  guide  to  the  quan- 


240  INFANT   FEEDING    (CHICAGO   METHODS) 

tity  of  food  must  be  the  weight  curve,  rather  than  the  condition 
of  the  stools. 

The  general  treatment  must  be  that  of  intoxication,  with 
particular  emphasis  upon  the  protection  of  the  child  from  all 
dangerous  external  influences.  He  must  be  well  cared  for,  pro- 
tected from  infections,  and  guarded  from  extremes  of  heat  and 
cold. 

Our  hour  is  now  up.  I  have  tried  to  impress  you  with  the 
importance  of  looking  upon  these  children  as  children  in  whom 
the  entire  nutrition  is  changed.  In  treating  such  a  baby,  under 
no  circumstances  let  the  condition  of  the  stool  control  you. 
The  stools  are  only  symptoms  of  the  condition  of  the  gastro- 
intestinal tract.  The  gastro-intestinal  tract  is  simply  a  means 
of  your  introducing  proper  elements  of  food  into  the  baby.  If 
you  decide  that  a  child  needs  carbohydrate,  then  you  must  give 
it.  Even  though  the  digestive  tract  rebel;  even  though  diar- 
rheal stools  point  to  fermentation,  don't  lose  your  courage  pro- 
vided the  weight  curve  does  not  begin  to  sink.  In  the  latter 
case,  under  no  circumstances  totally  withdraw  the  carbohy- 
drate. Humor  the  digestive  tract.  Change  your  food  combi- 
nation. Give  your  carbohydrate  in  the  combinations  in  which 
it  will  be  relatively  harmless,  such  as  breast  milk  or  albumin 
milk,  but  don't  give  up  your  principles.  With  a  httle  com- 
promise, a  little  shifting  of  technic,  a  wise  general  can  make 
the  digestive  tract  his  obedient  servant.  Never  under  any  cir- 
cumstances let  it  become  your  master. 

Question  (by  Dr.  Flippen,  Pilot  Mountain):  Doctor,  in  the 
treatment  of  your  older  children  the  diet  seems  to  be  much  the 
same,  both  in  intoxication  and  in  decomposition.  If  the  treat- 
ment is  the  same,  what  can  be  the  difference  in  the  two  condi- 
tions? 

Ansioer. — Intoxication  is  an  acute  affair,  the  symptomatology 
being  induced  perhaps  by  the  very  rapid  loss  of  water  from  the 
body.  Intestinal  fermentation  induced  by  any  cause  is  the 
primary  factor.  Decomposition  is  a  chronic  condition,  lasting 
for  weeks  or  even  months,  the  symptomatology  being  induced  by 
destruction  of  body  tissue  from  various  causes.  There  is  a 
gradual  loss  of  protein  and  mineral  matter  from  the  tissues,  the 


DECOMPOSITION  241 

intestine  suffers  secondarily,  and  thus  fermentative  processes  are 
easily  established. 

Our  treatment  in  intoxication  is  primarily  to  allow  the  intes- 
tine to  rid  itself  of  irritants,  and  then  to  give  a  feeding  which  will 
overcome  the  fermentative  processes. 

In  decomposition  we  recognize  the  extreme  need  of  the  body 
for  food,  but  we  recognize  also  the  Hability  of  this  food  to  fer- 
ment in  the  intestine;  thus,  in  giving  food  we  must  give  it  just 
as  we  would  in  intoxication,  in  non-fermentable  form.  We 
might  say  that  this  form  of  treatment  from  an  intestinal  stand- 
point is  an  active  treatment  in  intoxication  and  a  prophylactic 
one  in  decomposition. 

This  is  a  good  time  to  pause  and  to  consider  for  a  moment  the 
significance  of  the  entire  four  groups  of  cases:  disturbed  balance, 
dyspepsia,  intoxication,  and  decomposition.  Don't  make  the  mis- 
take of  so  many  and  think  this  was  Finkelstein' s  entire  classifica- 
tion. Like  Czerny,  Finkelstein  recognized  intestinal  disturbances 
due  to  many  different  factors.  His  great  service,  however,  was  to 
teach  us  the  importance  of  food,  and  to  demonstrate  four  clinical 
pictures  with  characteristic  weight  carves,  in  which  food  played  an 
important  part.  In  some  of  these,  primary  fermentation  of  sugar 
featured  prominently  in  the  etiology  and  symptomatology.  To  speak 
of  the  entire  group,  however,  as  a  fermentative  group  does  not  give  us 
a  broad  enough  conception',  for  in  some,  putrefaction  predominates; 
in  others,  intestinal  fermentation  while  causing  much  of  the  symp- 
tomatology, is  secondary  to  influences  besides  those  of  food;  and  in 
the  largest  group,  the  symptoms  are  brought  about  not  by  fermenta- 
tion alone,  but  by  fermentation  plus  a  great  variety  of  other  factors. 
These  are  not  exclusively  intestinal  affairs,  but  are  true  distur- 
bances OF  NUTRITION.  The  Middle  West  has,  from  the  beginning, 
taken  to  these  ideas  readily,  and  like  Finklestein  we  believe  that 
this  conception  of  disturbance  of  nutrition  is  a  valuable  aid  in 
the  therapy  of  the  majority  of  those  cases  usually  described  as  the 
gastro-intestinal  diseases  of  infancy. 


16 


LECTURE  Vn 
PARENTERAL  AND  ENTERAL  INFECTIONS 

Gentlemen,  we  now  have  finished  Finkelstein's  original  classi- 
fication. You  remember  that  pathology,  bacteriology,  and 
etiology  failed  us,  and  for  the  present  we  decided  clinical  obser- 
vation to  be  safest.  Do  not  for  a  moment  think  that  the  last 
word  has  been  said.  We  are  learning  every  day.  New  factors 
are  being  added,  old  ideas  changed;  but  if  we  keep  the  clinical 
picture  constantly  before  us,  we  shall  not  go  far  astray.  To 
show  what  the  clinical  viewpoint  has  accomphshed,  let  me  re- 
mind you  of  the  modification  of  Czerny's  idea  of  "milk  injury" 
effected  by  cHnical  studies.  Bedside  observation  and  reasoning 
added  the  factors  of  improper  care,  nursing,  post-infection,  and 
insufficient  sugar.  In  the  same  way  I  wish  to  show  this  morn^ 
ing  how  careful  observation  has  increased  our  knowledge  of 
dyspepsia. 

The  original  viewpoint  of  Finkelstein  was  that  all  cases  of 
dyspepsia  were  due  to  sugar.  Later  this  was  modified  to  sugar 
and  whey.  For  a  moment  he  was  side-tracked,  concentrating 
too  exclusively  on  the  one  symptom — the  acid  watery  stool ;  but 
clinical  observation  and  thought  saved  the  day.     To  illustrate: 

1.  In  his  institution  ten  babies  lie  in  each  ward.  Frequently 
after  thriving  for  three  or  four  weeks  every  baby  in  a  certain 
ward  developed  diarrhea.  Had  we  focused  our  attention  ex- 
clusively upon  the  stools,  we  probably  would  have  observed  a 
few  curds  of  fat,  a  little  mucus,  an  acid  reaction,  and  would  have 
said,  "Too  much  fat"  or  "Too  much  sugar"  or  "Too  much 
something  else,"  and  changed  the  inoffensive  baby's  diet.  As 
a  matter  of  fact,  by  keeping  the  broader  picture  before  us,  in- 
quiring into  every  cause  that  could  be  concerned,  we  learned 
that  the  day  preceding  the  disturbance  there  had  been  a  change 
of  nurses  in  the  ward.  This  observation  was  repeated  fre- 
quently.    Almost  invariably  when  a  new  nurse  began  her  duties 

242 


PARENTERAL  AND  ENTERAL  INFECTIONS        243 

the  children  temporarily  became  ill.  Why  a  change  of  nurses 
should  cause  such  a  reaction  I  don't  know.  As  I  have  said  so 
often,  "This  is  clinical  observation."  Perhaps  the  secret  lies 
in  psychic  or  nervous  influences.  At  any  rate,  it  was  perfectly 
independent  of  food. 

2.  Observations  -have  shown  that  heat  is  important.  This 
stimulated  the  very  excellent  research  of  McClure  and  Sauer  at 
the  Children's  Memorial  Hospital  of  Chicago.*  In  very  inter- 
esting experiments  they  showed  that  retained  heat  is  more  im- 
portant than  is  the  general  temperature.  A  baby  lightly  clothed 
on  a  very  hot  day  is  less  likely  to  become  dyspeptic  than  is  an 
overclothed  baby  during  milder  weather. 

3.  Keeping  the  broad  clinical  conception  of  "disturbance  of 
nutrition"  before  their  eyes,  Finkelstein  and  his  assistants  made 
other  important  observations.  A  new  baby  entered  the  ward; 
in  a  day  or  two  every  child  would  vomit  and  show  watery,  green, 
mucous  stools.  Clinical  pictures  varied  from  dyspepsia  to  in- 
toxication or  decomposition.  Had  we  studied  the  stools  ex- 
clusively we  would  have  said,  "This  child  has  received  too  much 
fat;  or  this  one  too  much  sugar";  but  keeping  a  broader  con- 
ception before  us,  trying  to  consider  every  factor  possible,  we 
learned  that  the  secret  of  the  matter  was  simply  this :  the  food 
upon  which  the  baby  previously  had  been  thriving  could 
scarcely  be  the  primary  factor.  The  new  baby,  however,  had  a 
little  cough  or  cold,  a  little  nasopharyngitis  or  grip,  and,  if  she 
were  a  little  girl,  a  cystitis.  During  the  following  days  every 
child  in  the  ward  started  to  cough  and  to  sneeze,  and,  folloioing 
this  infection,  reacted  with  diarrhea.  So  frequently  was  this 
observed  that  the  men  in  that  institution  and  in  others  I  visited 
came  to  believe  that  these  secondary  diarrheas — secondary  to 
little  infections — were  of  as  great  or  even  greater  importance 
than  the  primary  food  disturbances.  To  these  infections  they 
gave  the  name  "parenteral  infections,"  signifying  thereby  in- 
fections in  some  part  of  the  body  other  than  the  intestinal  tract. 
Gentlemen,  under  no  circumstances  forget  secondary  distur- 
bances due  to  parenteral  infections.  They  constitute  a  large  part 
of  the  diarrheal  cases  occurring  in  your  children's  practice. 

Are  you  beginning  to  understand  how  the  clinical  classification 
*  American  Journal  of  Diseases  of  Children,  1915,  ix,  490. 


244  INFANT   FEEDING    (CHICAGO   METHODS) 

of  Finkelstein  is  helping  our  study?  I  do  not  for  a  moment 
consider  it  finished,  but  I  do  consider  it  a  most  valuable  outline, 
by  which  we  may  direct  further  observations. 

Parenteral  infections  are  so  important,  I  want  to  talk  about 
them  for  just  a  moment.  How  a  cough  or  a  cold  causes  diarrhea 
we  do  not  know.  Such  is  purely  bedside  observation;  but 
human  nature  seeks  explanations,  and  for  that  reason  I  offer  the 
following.  Understand,  however,  it  is  subject  to  great  modifica- 
tion and  change. 

As  in  the  primary  food  disturbance  the  whey  of  cow's  milk 
seems  to  injure  the  intestine  and  allow  bacteria  which  are  nor- 
mally present  in  the  large  intestine  to  flourish  in  the  upper  tract, 
so  in  these  parenteral  infections,  as  the  stools  are  of  the  "fer- 
mentative" type,  we  also  must  have  an  agency  stimulating  bac- 
terial growth  in  the  small  intestine.  How  can  a  parenteral  in- 
fection increase  intestinal  fermentation?  Two  ways  become 
apparent : 

1.  Finkelstein's  assistants  have  shown  that  during  the  prog- 
ress of  these  infections,  the  qualities  of  the  digestive  juices  are 
changed.  They  are  decreased  in  amount  and  in  activity.  As 
a  result,  two  influences  may  be  exerted : 

(a)  Undigested  food  and  sugar  will  proceed  lower  than  usual 
down  the  intestinal  tract. 

(6)  The  bacteria  of  the  large  intestine  may  come  up  ab- 
normally high. 

2.  Products  of  bacterial  action  in  the  nose  and  throat  may 
impair  the  function  of  the  intestinal  cells  and  decrease  their 
abiUty  to  keep  the  upper  intestine  sterile. 

In  this  way,  gentlemen,  you  see  conditions  in  the  small  in- 
testine are  those  predisposing  to  disturbance  of  nutrition.  Here, 
however,  the  effect  produced  is  not  by  the  concentrated  whey  of 
cow's  milk,  but  by  influences  perfectly  independent  of  food, 
namely,  the  products  of  the  parenteral  infection.  In  either 
case  the  presence  of  hungering  bacteria  in  the  small  intestine 
must  warn  us  that  feeding  fermentable  sugar  will  lead  to  the 
production  of  irritating  acids  and  resulting  diarrhea.  The  dis- 
turbance arising  from  the  latter,  to  distinguish  from  the  primary 
disturbance  induced  by  concentrated  whey  of  cow's  milk,  we 
call  a  secondary  disturbance  of  nutrition. 


PARENTERAL  AND  ENTERAL  INFECTIONS 


245 


Just  as  in  other  conditions,  this  cHnical  picture  also  is  in- 
fluenced greatly  by  the  factors  of  age  (the  younger  the  child, 
the  severer  the  reaction),  constitution,  nursing  and  care,  heat, 
and,  above  all  things,  food.  Babies  fed  on  mixtures  very  high 
in  carbohydrate  and  whey  show  the  severest  reactions, 

Diagnosis.-^The  diagnosis  is  relatively  easy. 

1.  History  shows  the  child  has  had  grip  or  febrile  disturbance, 
followed  by  diarrhea.  The  mother  calls  you  for  the  intestinal 
condition,  completely  ignoring  the  fundamental  factor.  Diar- 
rhea followdng  a  cold  practically  makes  the  diagnosis. 

2.  Food  withdrawal  for  twenty-fom-  hoiirs  causes  a  great  im- 
provement in  the  intestinal  condition  and  any  resulting  nutri- 
tional disturbance,  but  does  not  influence  the  temperature. 
The  following  day,  if  the  temperature  is  still  elevated,  careful 
examination  of  the  patient  shows  a  pneumonia  or.  an  otitis  or  a 
cj^stitis  that  may  not  have  been  evident  upon  first  examination. 

Treatment.— The  treatment  divides  itself  into  that  of  the 
primary  cause  and  of  the  secondary  nutritional  disturbance. 

The  primary  infection  is,  of  course,  to  be  treated  according 
to  its  nature. 

The  secondary  disturbance  is  to  be  guided  purely  and  simply 
by  the  weight  curve.  If  the  curve  rises  continuously,  as  is  the 
case  in  the  healthy  breast-fed  baby,  steady  gain  being  noted 
each  day  in  spite   of  abnormal  intestinal  movements,  let  that 


Dav8 

. 

; 

1 

i 

\ 

1 

i 

1 

6  oz 
4  OZ 

Z  Ot 
8  lb 

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ife< 

ti( 

a 

^ 

y^ 

^ 

y^ 

,^ 

y 

> 

r 

^ 

^ 

y 

^ 

^ 

Fig.  26, 


baby  alone!  (Fig.  26).     Don't,  under  any  circumstances,  change 
the  food.    See  the  picture!    Under  the  influence  of  the  parent- 


246 


INFANT   FEEDING    (CHICAGO   METHODS) 


eral  infection  a  little  fermentation  has  been  induced  in  the 
intestine,  but  there  has  been  no  nutritional  reaction  whatsoever. 
The  effect  is  purely  and  simply  local  and  intestinal,  and  needs  no 
more  food  treatment  than  does  the  irritated  nose  in  a  coryza. 
The  weight  curve  doesn't  even  show  the  reaction  of  a  dyspepsia. 
Another  type  of  reaction,  the  type  which  appears  in  the 
somewhat  undernourished  breast  baby  or  in  the  fairly  well- 
nourished  bottle  baby,  is  illustrated  as  follows  (Fig.  27).     At  A 


1 

> 

\ 

i 

( 

1 

1 

1 

% 

1 

8  oz 

6  oz 

4  oz 

2  oz 
6  1^ 

/ 

I 

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Xh 

tn 

/ 

V 

/' 

i 

y 

^1 

J 

^ 

' 

/ 

/ 

o 

. 

/ 

/ 

Zi 

Fig.  27. 


the  child  becomes  infected.  The  accompanying  fermentation  is 
severe  enough  to  produce  a  mild  dyspepsia.  The  change  in  the 
weight  curve  shows  that  baby's  nutrition  is  beginning  to  suffer. 
Shall  we  change  the  diet  in  this  case?  Let  the  baby  alone! 
Again  see  the  picture!  The  fault  was  not  primarily  with  the 
food.  It  lay  in  the  infection  of  the  nose,  throat,  or  bladder. 
A  mild  secondary  disturbance  of  nutrition  has  arisen,  but  if  we 
simply  wait  a  few  days,  the  cough  and  cold  will  disappear,  and 
after  the  injuring  factor  has  gone,  the  intestine  corrects  itself 
at  B,  the  weight  curve  starts  to  ascend  and  diarrhea  disappears. 
In  these  two  instances  treat  the  mother  as  you  will,  but  unless  he 
begins  to  lose  weight,  don't  treat  the  baby.  Let  him  take  as  much 
food  as  he  will.  He  drinks  less  than  his  normal  amount,  and  so 
spontaneously  prevents  the  occurence  of  a  secondary  distur- 
bance. 


PARENTERAL  AND  ENTERAL  INFECTIONS 


247 


Fundamentally  different  is  a  third  type  (Fig.  28),  occurring  in 
babies  fed  on  one-sided  carbohydrate  mixtures.  The  baby  on 
condensed  milk  or  barley  gruel,  the  baby  with  a  masked  type  of 
decomposition,  shows  a  sharp  and  severe  reaction.  With  the 
onset  of  the  infection  diarrhea  commences.  The  stools  may  not 
vary  markedly  from  those  of  the  other  children.  How  misled 
we  would  be  by  focusing  exclusively  upon  them!  But  the  child 
reacts  with  a  marked  disturbance,  varying  from  a  mild  dyspepsia 
to  the  severest  intoxication  or  decomposition.  In  these  cases 
forget  the  primary  factor.  From  his  cough  and  cold  the  mother 
may  think  the  baby  is  very  sick,  but  you  know  that  death  is 


Basra 

. 

: 

1 

; 

1 

1 

. 

t 

( 

' 

8  02 

\ 

f^ 

^ 

^ 

^ 

^, 

4  01 

/ 

V 

N 

/ 

/ 

y 

2  o: 
6  lb 

1 

/ 

\ 

/ 

\ 

/ 

r 

/ 

— ~. 

► 

Fig.  28. 


going  to  occur  not  from  the  infection,  but  from  the  severe  sec- 
ondary disturbance  of  nutrition.  First  and  foremost,  the  latter 
must  receive  your  immediate  attention,  and  you  treat  it,  de- 
pending upon  its  nature,  according  to  the  principles  laid  out  in 
previous  lectures. 

Two  symptoms  arising  in  the  course  of  a  parenteral  infection 
may  need  treatment: 

1.  Vomiting. — If  the  vomiting  be  due  to  a  primary  food  dis- 
turbance, the  child  recovers  upon  removal  of  the  primary  cause, 
namely,  the  food.  If,  however,  the  condition  arises  from  a 
parenteral  infection,  change  of  food  will  have  no  effect,  and 
unless  we  stop  the  vomiting  we  have  trouble.     In  these  cases 


248 


INFANT  FEEDING    (CHICAGO   METHODS) 


gentle  stomach  washing  is  of  value,  as  are  also  mildly  anesthetic 
drugs,  such  as  novocain,  in  doses  of  ^^  grain  before  each  meal. 
2.  Anorexia. — If  the  loss  of  appetite  is  due  to  food,  removal 
of  the  cause  will  cure  the  condition.  If  the  cause  of  anorexia, 
however,  is  the  parenteral  infection,  change  of  food  will  have  no 
influence.  In  these  cases  physicians  often  make  fatal  errors. 
One  often  hears,  "If  the  baby  won't  eat,  we'll  starve  him  to  it." 
No  graver  error  can  be  made  than  this.  The  cause  of  the  baby's 
loss  of  appetite  is  not  the  food,  but  is  the  product  of  the  paren- 
teral infection,  and  you  may  starve  him  and  starve  him,  but  his 
appetite  will  not  return.  What  you  accomplish,  however,  by 
introducing  the  factor  of  hunger  is  to  throw  him  into  the  state 


Da-vs 

1 

\ 

- 

! 

> 

) 

8  lb 

U  oz 

8    02 

4  oz 
7  lb 

> 

f 

[\ 

S^ 

S 

\ 

\ 

\ 

N 

\ 

\ 

\ 

L^ 

Fig.  29. 


of  decomposition  (Fig.  29).  Many  of  the  deaths  occurring 
during  mild  infections  are  due  not  to  this  cause,  but  to  the  fac- 
tor of  decomposition  developing  from  the  associated  anorexia. 
Gentlemen,  the  baby  must  have  food.  If  he  takes  it  in  no  other 
way,  use  a  stomach-tube.  I  don't  mean,  now,  that  you  must 
get  a  pump  and  pump  gallons  into  his  stomach,  but  you  must 
introduce  small  quantities,  enough  to  keep  him  alive,  and  of 
such  proportions  as  to  avoid  the  dangers  of  a  secondary  dyspep- 
sia or  intoxication. 

The  factors  of  heat,  of  food,  of  parenteral  infection,  and  of 
care  usually  are  all  concerned  in  these  dyspepsias  and  intoxica- 


PARENTERAL  AND  ENTERAL  INFECTIONS        249 

tions.     In   recognition   Finkelstein  suggests   classifying  them 
etiologically  as  follows: 

I.  Purely  alimentary  or  food  type. 
II.  Mixed  type  (in  which  all  influences  are  concerned). 


INFECTIOUS  DIARRHEAS 

Gentlemen,  we  have  now  finished  the  "Disturbances  of  Nu- 
trition." I  want  to  take  you  far  away  for  a  moment  to  view  an 
entirely  different  group  of  diseases.  While  the  success  of  high 
protein,  low  whey,-  non-fermentable  carbohydrate  was  attested 
by  the  consensus  of  opinion  of  the  whole  world;  while  in  the 
Finkelstein  clinic  a  great  international  assemblage  of  men  had 
collected, — men  from  America,  England,  Austria,  Russia,  Japan, 
Bulgaria,  Rumania,  Switzerland,  Portugal,  and  other  coun- 
tries,— all  testifying  to  the  great  influence  of  these  teachings,  a 
communication  came  from  A.  I.  Kendall,  of  the  Boston  Floating 
Hospital,  saying  that  the  treatment  of  severe  diarrhea  was  low 
protein  and  high  carbohydrate.  Could  anything  be  more  tan- 
talizing, more  aggravating?  Just  at  the  moment  when  we 
thought  the  problem  of  diarrhea  in  children  forever  solved, 
when  we  thought  the  infalUble  remedy  for  all  diarrhea  was  high 
protein,  low  whey,  non-fermentable  carbohydrate,  we  must 
read  that  the  proper  treatment  is  low  protein,  high  carbohy- 
drate, and  carbohydrate  in  a  fermentable  form,  such  as  lactose. 
The  first  inchnation  was  to  do  as  always,  when  some  one  dis- 
agrees with  us — to  question  the  writer's  sanity.  Careful  study 
of  the  pubhcation,  however,  showed  that  Kendall  was  speaking 
of  a  group  of  diseases  entirely  different  from  those  we  were 
studying.  His  work  had  to  do  with  the  true  infectious  diar- 
rheas— those  due  to  specific  microorganisms;  the  type  of  case 
we  did  not  see.  The  communication  was  so  interesting  that  I 
resolved,  upon  my  return  to  this  country,  to  try  to  meet  Ken- 
dall. To  my  great  pleasure  I  learned  that  he  had  been  called  to 
take  charge  of  the  Department  of  Bacteriology  at  Northwestern 
University  Medical  School,  the  institution  with  which  I  was  to 
be  connected.  He,  with  the  true  interest  of  the  bacteriologist, 
was  concerned  mainly  with  the  deadly  infectious  diarrheas:  I 
chiefly  with  the  question  of  nutrition.    To  settle  the  point  as 


250  INFANT   FEEDING    (CHICAGO   METHODS) 

regards  the  nature  of  material  in  Chicago,  we  made  a  study 
during  the  summer  of  1914. 

Dr.  Alexander  Day,  one  of  Kendall's  associates  on  the  Boston 
Floating  Hospital,  examined  bacteriologically  all  cases  of  severe 
diarrhea  in  our  wards.  He  cultured  carefully  all  the  stools, 
while  I  studied  the  cases  from  the  standpoint  of  "nutritional 
disturbance,"  looking  at  them  clinically  and  noting  their  weight 
and  food  reactions.  Our  results  showed  that,  during  this  sum- 
mer, in  our  wards  in  Chicago,  one  or  two  cases  of  diarrhea  showed 
the  gas  bacillus  in  the  stools;  two  cases  showed  reactions  to  food 
typical  of  the  primary  food  disturbances,  and  the  remainder 
were  those  associated  with  coughs  and  colds — the  so-called 
parenteral  infections.  During  a  study  made  the  following  year 
we  found  two  cases  of  severe  dysentery  sent  to  the  hospital 
from  out  of  town — cases  entirely  different  in  nature  from  our 
own,  and  showing  symptoms  identical  in  every  respect  to  the 
dysentery  infection  which  Kendall  had  noted  in  Boston.  In  the 
stools  Dr.  Day  discovered  the  true  organisms  of  dysentery. 

Why  is  it  that  in  Boston  infectious  dia'rrheas  and  in  Chicago 
nutritional  disturbances  prevail?  The  failure  to  discover  in- 
fectious diarrheas  in  Chicago  could  not  have  been  due  to  technic, 
as  the  investigations  were  conducted  by  the  same  men.  We 
must  regard  these  results  as  conclusive.  Day  and  I  offered  the 
explanation  that,  in  the  sense  of  Brennemann,  the  difference  may 
be  due  to  the  fact  that  in  the  East  raw  milk  had  been  used,  and 
in  Chicago,  boiled  milk.  Isn't  it  reasonable  to  assume  that  in 
the  East,  with  raw  milk,  infectious  diarrheas  prevail;  in  the 
middle  West,  where  these  organisms  have  been  removed  by 
boiling,  nutritional  disturbances  only  are  seen? 

Gentlemen,  in  this  part  of  the  country  probably  many  of  your 
patients  use  raw  milk.  When  you  are  called  to  see  a  baby  with 
diarrhea,  you  are  at  once  confronted  with  the  problem,  "Is 
this  an  infectious  diarrhea  or  is  it  one  of  the  nutritional  type?" 
To  distinguish  between  these  is  of  fundamental  importance. 
We  have  several  means. 

History. — The  acute  infectious  diarrhea  starts  suddenly  in  a 
previously  well  baby  and  prostrates  him  at  once.  The  nutri- 
tional disturbance  comes  more  gradually.  In  the  latter  we 
get  a  history  of  improper  feeding,  of  previous  nutritional  dis- 


PARENTERAL   AND    ENTERAL   INFECTIONS  251 

turbance,  of  parenteral  infection.  It  is  more  gradually  pro- 
gressive. 

Stools. — These  are  of  considerable  aid  in  our  diagnosis.  In 
the  infectious  diarrhea,  particularly  dysentery,  they  are  very  fre- 
quent, small,  and  chiefly  blood-stained  mucus.  They  contain 
barely  any  soUd  material,  and  the  microscope  reveals  pus. 
They  may  be  identical  to  the  evacuations  in  intussusception. 
The  reaction  in  dysentery  is  alkaline.  In  nutritional  distur- 
bance the  stools  are  green,  usually  acid,  and  watery.  They  con- 
tain increased  solid  material  and  some  mucus;  rarely  blood  or 
pus  unless  the  case  has  long  been  neglected. 

The  reaction  to  food  is  of  value.  If,  after  twenty-four  hours 
of  tea,  the  temperature  continues  high,  the  weight  curve  sinks, 
the  diarrhea  continues,  with  small,  bloody,  mucous  stools,  then 
some  factor  other  than  food  must  be  at  hand.  If  careful  physical 
examination  rules  out  parenteral  infection,  such  as  pneumonia 
or  sepsis,  the  diagnosis,  by  exclusion,  will  be  enteral  infec- 
tion. 

Treatment. — Gentlemen,  what  I  have  to  tell  you  about  the 
treatment  of  true  infectious  diarrheas  will  be  disappointing. 
All  that  I  can  do  is  to  expose  our  ignorance.  The  treatment  de- 
pends just  as  absolutely  upon  definite  bacteriologic  diagnosis  as 
that  of  diphtheria  depends  upon  throat  culture.  How  to  treat 
cases  of  infectious  diarrhea  in  this  part  of  the  country  I  do  not 
know,  for  I  have  absolutely  no  idea  what  types  of  infection  you 
meet.  If  it  is  a  gas  bacillus,  one  food  must  be  given;  if  it  is  a 
dysentery  bacillus,  radically  the  opposite  treatment  must  be 
instituted.  Bacteriologic  methods  of  diagnosis  are  difficult — a 
trained  bacteriologist  is  necessary.  An  agglutination  reaction 
in  dysentery,  such  as  the  Widal  in  typhoid,  can  be  of  service. 
All  that  I  can  do,  gentlemen,  is  to  urge  you,  in  connection  with 
your  medical  society,  to  cooperate  with  the  State  Board  of 
Health  or  with  the  State  University  in  attempting  to  discover 
what  types  of  infection  exist  here. 

I  won't  bother  you  with  the  technic  for  isolating  the  dysen- 
tery organisms.  The  gas  bacillus,  however,  can  be  detected 
relatively  simply: 

To  get  a  sterile  specimen  of  the  baby's  stool,  round  the  ends 
of  a  piece  of  sterile  glass  tubing  about  the  thickness  of  a  lead- 


252  INFANT   FEEDING    (CHICAGO    METHODS) 

pencil,  and  insert  it  into  the  rectum  as  you  would  a  thermometer. 
Usually  a  little  fecal  material  enters.  If  the  rectum  is  empty, 
repeat  in  an  hour.  Then  inoculate  a  small  quantity  of  the  stool, 
about  the  size  of  a  pea,  into  a  test-tube  of  milk.  This  is  heated 
to  180°  F.  for  half  an  hour.  All  bacteria  are  killed  except  the 
spores,  which  resist  heat,  and,  when  the  milk  is  incubated  at 
body  temperature,  grow  rapidly.  If  they  be  those  of  the  gas 
bacillus,  they  split  sugar  into  acetic  and  butyric  acids,  and  char- 
acteristically give  the  odor  of  rancid  butter.  Secondly,  the 
acid  causes  the  casein  to  coagulate.  This  precipitates  in  large 
curds,  but,  due  to  the  growth  of  the  gas  bacillus,  has  the  appear- 
ance of  being  completely  "shot  to  pieces."  Lastly,  the  micro- 
scope shows  the  large  Gram-positive  bacillus. 

The  treatment  for  gas  bacillus  infection,  according  to  Kendall, 
is  based  upon  the  observations  that  the  organism  grows  well  in 
sugar  and  does  not  grow  well  on  high  protein  or  lactic  acid.  In 
such  an  infection,  therefore,  the  treatment  is  buttermilk.  Al- 
bumin milk,  due  to  its  high  protein,  low  carbohydrate,  and  lactic 
acid,  would  also  be  ideal.  Kendall  made  the  interesting  sug- 
gestion that  perhaps  some  of  the  cases  that  Finkelstein  treated 
so  successfully  with  albumin  milk  were  really  those  of  gas  bacil- 
lus infection.  This  is  a  very  interesting  suggestion,  but  I  don't 
believe  will  prove  true  as  a  general  rule. 

The  treatment  of  true  infectious  dysentery  is  based  upon 
entirely  different  principles.  Here  great  ragged  ulcers  line  the 
intestine.  In  these  the  dysentery  organisms  Uve  and  produce 
toxins,  just  as  do  diphtheria  bacilli,  from  their  location  in  the 
throat.  Death  occurs  in  dysentery  largely  from  toxemia.  You 
see  then,  gentlemen,  how  hopeless  is  drug  therapy.  We  may 
give  calomel.  We  may  give  medication  to  flush  out  the  intes- 
tine. With  small  quantities  we  may  do  no  harm.  -To  me, 
however,  giving  cathartics  in  such  cases  suggests  reaching  in 
with  a  forceps  and  tearing  out  the  membrane  of  diphtheria. 
What  folly!  If  our  sole  therapy  in  diphtheria  is  physical  injury, 
we  kill  the  baby.  Our  treatment  lies  in  antitoxin;  and  so  it  is 
with  dysentery.  Our  ultimate  success  must  he  in  the  adminis- 
tration of  antitoxin  if  we  can  give  it  in  time. 

In  speaking  of  calomel,  gentlemen,  I  understand  that  it  is 
used  considerably  down  here  and  that  you  place  great  faith  in  it. 


PARENTERAL  AND  ENTERAL  INFECTIONS        253 

It  may  be  very  efficient.  I  do  not  know,  because  I  do  not  know 
the  existing  types  of  infection.  May  be  you  have  organisms  to 
which  calomel  is  deadly.  That  remains  to  be  seen.  After  all, 
the  wisest  is  to  establish  means  for  obtaining  definite  diagnosis. 

The  general  treatment  of  dysentery  must  be  that  of  all  in- 
fectious disease.  Keep  up  the  fluids,  provide  proper  nursing 
and  care,  stimulate  if  necessary.  Opium  is  of  great  value.  In 
nutritional  diarrheas  opium,  by  disguising  the  symptoms,  might 
lull  us  into  an  insecure,  dangerous  self-satisfaction.  In  dysen- 
tery, however,  where  the  bacillus  and  not  the  food  is  the  cause, 
we  disguise  no  symptoms  with  opium,  but  quiet  our  httle  pa- 
tient and  relieve  the  pain  and  tenesmus.  Give  as  much  as  you 
can  with  safety.  As  regards  medication,  quinin  tannate,  in 
doses  of  3  to  5  grains  three  times  a  day,  is  highly  recommended; 
but,  as  I  have  said  so  frequently,  do  not  put  too  much  confidence 
in  drugs. 

The  dietetic  treatment  is  radically  different  from  that  of 
nutritional  disturbance  and  from  gas-bacillus  infection.  Theo- 
bald Smith,  the  great  American  bacteriologist,  years  ago  ob- 
served that  if  the  diphtheria  bacillus  be  grown  on  carbohydrate 
it  will  not  produce  toxin,  but  if  grown  on  protein,  it  produces 
the  typical  toxin  of  diphtheria.  Kendall,  working  from  this 
viewpoint,  experimented  with  dysentery  and  found  that  if  it 
be  grown  on  carbohydrate,  no  poison  is  produced,  while  if 
grown  on  protein,  the  deadly  dysentery  toxin  results.  This 
explains,  then,  why  in  dysentery  he  advocated  high  carbohy- 
drate feeding.  He  wished  to  get  carbohydrate  to  the  organisms 
growing  in  the  intestine,  thus  preventing  the  formation  of  toxin. 
Two  forms  of  dietetic  treatment  may  be  employed: 

1.  Breast  Milk. — Breast  milk  with  low  protein  and  high  car- 
Dohydrate  is  a  food  ideal  for  Kendall's  requirements,  and  at  the 
same  time  does  not  endanger  the  child  from  a  nutritional  stand- 
point. 

2.  The  Frank  Treatment. — This  is  the  most  successful  of 
artificial  feedings.     I  give  it  as  recommended: 

(a)  Tea  for  twenty-four  hours,  except  in  cases  of  decomposi- 
tion. 

(6)  On  the  second  day  start  with  five  feedings,  each  of  which 
is  composed  of  two  ounces  of  whey  and  two  ounces  of  gruel. 


254  INFANT   FEEDING    (CHICAGO   METHODS) 

(c)  Gradually  increase  by  the  fourth  or  fifth  day  to  five  feed- 
ings of  2^  ounces  each. 

(d)  On  the  fifth  to  the  eighth  day,  in  teaspoonful  doses,  slowly 
replace  the  whey  by  milk.  See  the  importance  of  diagnosis! 
We  have  ordered  a  mixture  of  sugar,  salts,  and  barely  any  pro- 
tein for  five  days.  This  would  have  been  the  worst  possible  in 
nutritional  disturbance  or  gas-bacillus  infection. 

(e)  On  the  twelfth  to  fourteenth  day,  perfectly  independent 
of  the  stools,  the  patient  must  be  getting  13  to  14  ounces  of  gruel, 
13  to  14  ounces  of  milk,  and  6  to  7  ounces  of  broth.  He  also  may 
receive  a  Httle  cereal,  as  rice,  farina,  Cream  of  Wheat,  etc.,  and, 
if  over  one  year  of  age,  a  little  meat. 

This  is  the  most  successful  up-to-date  treatment  for  infection 
with  true  dysentery.  How  complicated,  how  long,  often  how 
unavaiUng!  Why  not  with  one  stroke  save  your  patients  and 
yourselves  all  this  wearisome  treatment  and  danger,  practise  a 
Uttle  prophylaxis,  and  hoil  the  milk? 

We  have  now  finished  the  subject  of  nutritional  diseases. 
We  have  given  you  some  of  the  viewpoints  developed  in  the 
great  European  clinics  and  adopted  in  the  middle  West.  You 
may  have  wondered  at  the  hours  given  to  nutritional  conditions, 
and  have  been  disappointed  in  the  few  words  given  to  infection. 
Time  prevents  a  thorough  consideration  of  everything.  I  laid 
most  emphasis  upon  the  former,  with  the  idea  of  preparing  you 
for  the  future.  I  believe  that  if  you  boil  your  milk,  disturbance 
of  nutrition  will  be  the  type  preeminent,  the  picture  which  will 
become  more  and  more  apparent  in  your  practice. 

I  have  spoken  chiefly  of  our  ideas  in  Chicago.  Other  view- 
points you  may  obtain  from  the  many  excellent  American  text- 
books on  the  subject.  We  prefer  the  clinical  classification  be- 
cause we  believe  the  broad  conceptions  in  it  will  aid  us  in  further 
study.  We  like  the  term  "disturbance  of  nutrition,"  rather 
than  that  of  gastro-intestinal  disease,  because  we  believe  this 
conception  prevents  our  focusing  too  closely  upon  the  stool. 
Even  though  the  primary  causative  factor  lay  in  the  intestinal 
canal,  we  believe  the  baby's  general  condition  far  more  im- 
portant than  his  gastro-intestinal  tract.  Our  whole  plan  of 
feeding  and  therapy  depends  not  upon  the  stool,  but  upon  the 
weight  curoe.   We  beUeve  the  latter,  if  controlled  by  conscientious 


PARENTERAL  AND  ENTERAL  INFECTIONS        255 

history  and  physical  examination,  gives  the  best  index  of  the 
baby's  general  condition,  of  the  combined  influences  exerted  by 
"food,^'  by  "intestine,^'  and  by  "demands  of  the  body." 

Just  one  word  more.  A  recent  communication  of  1916  from 
Dr.  Louis  W.  Hill,  of  Boston,  who  is  conducting  so  successfully 
the  sections  in  the  East,  divides  diarrheas  into  three  groupis, 
namely : 

1.  The  infectious  type. 

2.  The  nervous  type. 

3.  The  fermentative  type. 

Regarding  the  latter,  he  goes  into  some  length,  showing  the 
antagonistic  effects  of  protein  and  carbohydrate,  laying  emphasis 
upon  carbohydrate  fermentation  in  the  production  of  the  irri- 
tating lower  fatty  acids,  and  recognizing  carbohydrate  as  a 
primary  factor  even  in  some  cases  where  much  fat  is  excreted. 

There  must  then  be  very  little  difference  between  the  opinions 
of  the  East  and  middle  West.  Why  have  we  disputed?  Powers 
of  observation  do  not  depend  upon  geographical  location. 
There  must  be  some  deeper  factor,  some  truer  explanation. 
One  thought  constantly  repeats  itself  in  my  mind:  Cannot  the 
whole  difference  be  explained  upon  the  basis  of  boiled  milk? 
Isn't  it  possible  that  conditions  in  the  East  are  undergoing  evo- 
lution ;  that  during  the  period  of  raw  milk,  pictures  of  the  spec- 
tacular, deadly  infectious  diarrheas  exclusively  prevailed?  But 
now,  as  I  understand  it,  boiled  milk  is  coming  into  its  own. 
Isn't  it  possible  that  for  the  first  time,  the  gradual  waning  of 
infectious  diarrhea  reveals  the  rise  of  disturbances  of  nutrition? 
We  eagerly  shall  await  new  developments. 


'     LECTURE  Vm 
ARTIFICIAL  FEEDING  OF  THE  NORMAL  INFANT 

Gentlemen,  artificial  feeding  in  the  middle  West  has  developed 
from  the  studies  we  have  described.  We  never  start  with  a 
preconceived  idea  as  regards  a  definite  and  exact  formula,  but 
by  knowledge  of  the  various  disturbances  arising  from  improper 
combinations  we  select  mixtures  to  avoid  them.  The  funda- 
mental requisite  in  infant  feeding  is  a  little  good  common  sense. 

Before  going  into  detail,  it  might  be  well  to  rid  ourselves  of  a 
few  conceits.  A  young  animal,  even  if  starved,  nevertheless 
continues  to  grow.  He  will  not  gain  in  weight,  but  he  will  in 
size.  So  it  is  with  the  baby.  Don't  for  a  moment  think  that 
you  are  responsible  for  the  baby's  growing.  You  simply  offer 
him  bricks  and  mortar  for  his  tissues,  but  you  certainly  are  not 
responsible  entirely  for  his  growth.  Don't  take  yourselves  too 
seriously.  You  are  an  outside  factor,  an  external  influence — 
important,  it  is  true,  but  by  no  means  the  sole  cause  of  baby's 
thriving. 

Remember  that  the  mother  does  not  feed  the  baby  at  the 
breast.  The  baby  feeds  himself.  The  mother  does  not  start 
with  the  preconceived  idea  of  how  much,  of  how  many  ounces, 
she  is  going  to  give  the  baby.  She  simply  puts  him  to  the  breast, 
he  takes  what  he  wants,  and  when  satisfied,  stops. 

Gentlemen,  get  the  idea  out  of  your  head  that  you  are  going 
to  feed  the  baby.     Leave  a  litttle  of  the  responsibihty  to  him ! 

Remember,  by  all  means,  that  the  baby  is  human.  Think  of 
yourselves,  for  instance;  your  appetite  varies  depending  upon 
the  weather,  upon  your  mood,  upon  the  nature  of  the  food. 
On  a  hot  day  you  eat  less;  on  a  cold  day,  more.  Amounts  vary 
daily.  Some  of  you  are  vegetarians;  some  of  you  meat  eaters; 
some  of  you  not  particular.  So  it  is  with  the  baby.  Remember 
that  he  is  human,  that  his  appetite  will  vary,  that  no  two  babies 

256 


ARTIFICIAL   FEEDING    OF   THE   NORMAL   INFANT  257 

are  alike;  meet  him  half-way,  and  rather  than  expect  all  con- 
cessions from  him,  make  a  reasonable  attempt  to  adjust  your 
mixtures  to  his  demands. 

Remember  that  when  we  eat  our  fundamental  worry  is  "will 
this  food  agree  with  us?"  If  we  take  our  meal  without  digestive 
trouble;  if  we  get  the  food  past  the  intestinal  tract  into  the 
body,  our  troubles  largely  are  over.  The  body  uses  what  it 
needs  and  throws  out  the  excess.  Why  should  the  baby  be 
different?  Any  food  which  easily  and  harmlessly  passes  the 
intestinal  tract  into  the  body,  and  at  the  same  time  contains 
enough  bricks  and  stones  and  mortar  for  the  body  tissues,  will 
provide  for  the  baby's  growth.  He  retains  what  he  needs  and 
casts  out  any  excess,  whether  it  be  breast  milk  or  cow's  milk. 

Thus,  you  see,  many  systems  of  feeding  may  be  successful. 
There  is  no  one  system  which  is  exclusively  right — many  meth- 
ods are  right.  Our  main  concern  is  simplicity.  We  must  ans- 
wer the  body  requirements  and  emplo}^  the  intestine  simply  as 
an  agent  for  introducing  food-stuffs. 

How  often  shall  we  offer  food?  Opinion  varies  from  two  to 
four  hours.  Czerny  advises  adhering  rigidly  to  the  four-hour 
schedule — five  feedings  in  twenty-four  hours:  at  6,  10,  2,  6,  and 
10  o'clock,  and  from  10  at  night  to  6  in  the  morning  the  baby  to 
receive  nothing.  He  insists  upon  this  schedule  for  all  babies, 
and  undoubtedly  this  method  is  attended  with  much  success. 
The  claims  in  favor  of  it  are:  first,  it  is  scientific  (based  upon 
physiological  reasoning),  and  second,  it  is  a  great  help  and  con- 
venience to  the  mother.  From  my  own  experience,  I  find  many 
children  do  well  on  four-hour  nursings,  but  it  seems  to  me  also 
that  manj'  of  those  under  two  to  three  months  do  not  seem 
satisfied  when  made  to  wait  so  long  and  do  better  on  a  three- 
hour  schedule.  And  so,  as  a  matter  of  routine,  I  order  for  all 
children  under  two  to  three  months  seven  feedings — at  6,  9,  12, 
3,  6,  and  9  o'clock  and  once  during  the  night.  Undoubtedly, 
however,  many  of  these  would  do  just  as  well  on  the  Czerny 
system,  and  when  they  do,  it  is  a  great  convenience  to  the 
mother. 

Recently  the  very  interesting  experimental  work  of  Professor 
A.  J.  Carlson,  of  the  University  of  Chicago, — who  has  done  so 
much  to  clear  up  the  physiology  of  hunger, — goes  to  show  that 
17 


258  INFANT  FEEDING   (CHICAGO  METHODS) 

perhaps,  after  all,  the  three-hour  system  is  based  upon  more 
scientific  principles  than  the  four-hour  one. 

The  number  of  feedings  varies  somewhat  with  locahty.  I 
beUeve  in  the  East  they  feed  more  frequently  than  we  do.  A 
simple  experiment  which  we  made  in  the  Finkelstein  Clinic 
might  explain  these  differences.  Babies  in  some  wards  we  fed 
according  to  the  percentage  method;  babies  in  others  we  fed 
according  to  the  methods  I  am  about  to  teach  you.  All  were 
given  five  feedings  in  twenty-four  hours.  The  percentage 
babies  vomited  more  than  did  the  others.  As  the  percentage 
method  frequently  requires  more  fat  than  does  ours,  we  rea- 
soned that  this  vomiting  might  possibly  be  due  to  the  fat,  i.  e., 
to  the  irritating  lower  fatty  acids  contained  in  cow's  milk  fat. 
Empirically  we  controlled  this  vomiting  by  feeding  smaller 
quantities  more  frequently;  so  in  a  short  time  all  the  percentage 
babies  received  several  more  feedings  a  day  than  did  the  others, 
and  all  thrived  beautifully.  This  may  help  explain  the  differ- 
ence in  the  various  feeding  schedules. 

What  shall  we  offer?  Almost  any  system  of  feeding  has  its 
ardent  advocates.  The  possibihties  of  the  normal  child's  in- 
testinal tract  are  immense.  The  normal  baby  thrives  upon  a 
great  number  of  mixtures.  Therefore  it's  easy  to  understand 
how  many  different  systems  have  arisen,  each  with  its  enthusias- 
tic adherents.  The  French,  for  instance,  have  at  times  recom- 
mended full  boiled  milk.  Many  children  do  well  on  this;  some 
don't.  Biedert,  one  of  the  older  German  pediatricians  (he  it 
was  who  first  described  casein  curds  in  the  baby's  stool),  recom- 
mended the  dilution  of  whole  milk  to  lower  the  protein.  To 
make  up  for  the  loss  in  strength  he  added  cream  and  sugar. 
The  resulting  combination  resembled  somewhat  a  percentage 
mixture.     Some  children  thrived  beautifully;   some  did  not. 

Heubner  brought  calories  to  our  notice.  He  first  advocated 
feeding  45  calories  per  pound  body  weight  for  children  under 
six  months.  This  system  is  not  ideal,  as  you  readily  see.  A 
child's  bottle  may  contain  the  proper  number  of  calories,  but 
they  may  be  only  in  fat  or  in  sugar,  and  will  not  satisfy  the  de- 
mands of  his  body  tissues.  Again,  newer  studies  show  that 
mysterious  invisible  substances,  called  vitamins,  play  important 
roles  in  growth.     The  excellent  work  of  the  men  at  the  Uni- 


ARTIFICIAL   FEEDING   OF   THE   NORMAL  INFANT  259 

versity  of  Wisconsin  already  has  subdivided  this  new  group  into 
fat-soluble  substances  found  in  butter,  and  water-soluble  sub- 
stances found  in  wheat  embryo,  both  of  which  are  absolutely 
essential  to  an  animal's  growth.  These,  of  course,  cannot  be 
measured  by  caloric  value.  We  of  the  Middle  West  do  not 
follow  rigidly,  but  we  value  the  caloric  system  chiefly  as  a  check 
upon  us,  and  when  a  baby  is  not  gaining,  we  occasionally  run 
over  the  formula  and  estimate  approximately  how  many  calories 
it  represents.  But  let  me  emphasize  that  we  do  not  advocate 
this  as  a  method  of  feeding.  It  is  simply  a  check  upon  the  fuel 
value  of  food  that  we  are  offering. 

An  ingenious  advance  was  the  percentage  system,  used  by 
our  friends  in  the  P]ast.  It  was  first  devised  for  the  purpose  of 
making  the  relations  of  protein,  fat,  and  carbohydrate  in  cow's 
milk  similar  to  those  in  breast  milk,  but,  as  I  understand  it, 
now  is  offered  simply  "as  a  method  of  calculation  and  a  means 
of  attaining  relative  accuracy  in  the  preparation  of  infant's 
foods."  For  such  a  purpose  we  welcome  it  heartily.  We  of 
the  Middle  West  do  not  use  it,  not  because  we  object  to  accur- 
acy, but  because  we  find  the  percentage  formula?  somewhat 
cumbersome  and  because  we  accomplish  excellent  results  with 
methods  which  to  us  seem  simpler. 

Ludwig  F.  Meyer  once  said  to  me:  "What  an  ideal  combina- 
tion would  result  if  one  would  take  your  percentage  method  of 
feeding,  striving  as  it  does  for  accuracy,  and  adapt  it  to  the 
principles  we  are  attempting  to  develop!"  Gentlemen,  I  think 
tliis  would  be  a  step  in  the  right  direction.  In  this  entire  course 
I  have  attempted  to  teach  you  not  rules,  but  principles.  You 
know  that  in  infants  fed  with  boiled  milk  we  consider  most  dis- 
turbances due  to  fermentation  of  carbohydrate,  induced  either 
primarily  by  improper  relation  to  the  whey,  or  to  the  fat  and 
whey;  or  secondarily  to  one  of  many  parenteral  factors.  In  all 
cases,  however,  we  pay  far  more  attention  to  the  baby  as  a  whole 
than  to  his  intestinal  tract.  Gentlemen,  don't  forget  these 
principles.  With  them  you  may  face  any  nutritional  distur- 
bance with  equanimity.  Make  up  your  mixtures  as  you  will. 
By  all  means  strive  for  accuracy.  If  you  find  the  percentage 
method  of  calculation  of  value  as  a  check,  use  it.  From  our 
system  of  feeding,  however,  has  developed,  I  believe,  the  simplest 


260  INFANT   FEEDING    (CHICAGO   METHODS) 

technic  for  answering  the  above  requirements.  But  any  simpler 
method  of  calculation  which  will  enable  us,  while  still  being 
true  to  our  principles,  to  make  up  mixtures  with  even  greater 
accuracy,  we  shall  always  be  glad  to  adopt. 


METHODS  OF  THE  MmDLE  WEST 

Our  system  is  prophylactic  from  the  start.  We  have  learned 
that  the  fault  does  not  lie  exclusively  with  one  element  of  the 
milk:  that  it  depends  upon  improper  relations  of  the  different 
elements.  Thus,  if  we  give  much  sugar  in  concentrated  whey, 
diarrhea  results;  if  we  give  the  same  sugar  in  highly  diluted 
whey,  the  chances  of  disturbance  are  decreased.  If  we  give  fat 
in  combination  with  high  carbohydrate  in  a  medium  of  cow's 
milk,  we  frequently  have  trouble.  The  fat  may  be  involved 
either  primarily  or  secondarity.  If,  however,  we  give  this  very 
same  fat  in  combination  with  albumin  milk,  viz.,  with  high  pro- 
tein, low  whey,  and  non-fermentable  carbohydrate,  the  fat 
becomes  harmless.  Fat  in  an  acid  intestine  enhances  diarrhea; 
in  an  alkaline  intestine,  enhances  constipation.  Again,  we  may 
offer  rather  concentrated  whey,  even  as  full  milk,  which  the 
French  have  done,  and  experience  no  difficulty  whatsoever  until 
carbohydrate  is  added.  In  our  feeding  we  attempt  to  dilute  all 
elements  of  the  milk  and  to  make  our  additions  with  only  one. 
In  the  baby's  intestine  high  fat  and  high  sugar  in  cow's  milk  are 
not  agreeable  companions.  Prophylaxis  is  our  motto,  and  we 
proceed  as  follows: 

1.  To  protect  our  baby  from  dysentery  and  other  virulent 
infections,  and  to  prevent  the  formation  of  tough  casein  curds,  we 
boil  the  milk. 

2.  To  prevent  the  accusation  that  we  are  predisposing  to 
scurvy  we  add,  at  the  end  of  the  first  month,  orange-juice  in 
doses  of  a  teaspoonful  each  day.  Dr.  Alfred  Hess,  of  New 
York,  has  shown  this  to  be  extremely  important. 

3.  To  prevent  the  danger  of  overfeeding,  we  are  careful  as  to 
the  total  quantity  of  food.  How  much  do  we  offer?  Naturally, 
the  amount  in  each  bottle  must  depend  upon  the  fuel  value  of 
the  food  and  the  number  of  feedings:  the  more  frequent  the 
feedings,  the  less  the  individual  quantity.     But  don't  try  to 


ARTIFICIAL  FEEDING   OF   THE   NORMAL   INFANT  261 

follow  any  hard  and  fast  outline.  Remember,  we  are  treating 
babies,  not  manufacturing  rules.  In  a  general  way  the  first 
time  we  see  a  child  we  guide  ourselves  as  follows : 

(a)  By  the  end  of  the  second  week  an  infant  will  drink  in 
twenty-four  hours  a  total  of  roughly  15  ounces,  increasing  to 
20  ounces  by  the  end  of  the  first  month. 

(6)  During  the  second  month  he  increases  this  total  to  25 
ounces. 

(c)  During  the  third  month  he  drinks  a  quart 

This  is  no  rigid  routine.  Some  babies  take  more;  some  less. 
Try  the  baby  on  this  amount  and  see  how  he  reacts.  The  first 
formula  is  really  a  feeding  experiment. 

4.  To  protect  the  child  from  nutritional  disturbances  arising 
from  improper  relations  of  the  various  ingredients,  we  bear  the 
following  picture  in  mind.  I  do  not  believe  you  will  find  it 
formulated  just  as  I  give  it,  but  in  a  way  it  represents  our  point 
of  view  (Fig.  30). 


Distvurbed  Balance*^:'  i  "s^-Dyspepala 

DocompoSitlon  v  Intoxication 


This  illustration  shows  the  well  baby  included  in  the  group 
of  sick  babies,  and  suggests  that  this  very  same  well  baby  can  be 
made  to  assume  any  one  of  four  clinical  types.  The  factors 
concerned  in  these  changes  are  the  improper  usage  of  carbohy- 
drate and  whey  and  the  improper  understanding  of  the  role  of 
fat  as  a  secondary  factor.  The  conditions  on  the  right  develop 
from  too  high  carbohydrate  in  concentrated  whey;  the  condi- 
tions on  the  left  arise,  as  Czerny  would  have  said,  from  too  much 
fat;  as  Finkelstein  would  say,  from  too  little  sugar.  Of  course, 
constitution,  infection,  etc.,  are  important  accessory  agents. 

What  is  the  purpose  of  this  scheme?  It  suggests  that  our 
attitude  must  be  identical  to  that,  for  example,  in  typhoid  fever. 
In  typhoid  we  don't  treat  the  disease:  we  simply  try  to  guide  our 
patient  through  the  difficulties  that  lie  in  his  path;  and  so  it  is 
with  infant  feeding.     We  don't  feed  the  baby :  we  simply  guide 


262  INFANT   FEEDING    (CHICAGO   METHODS) 

him.  In  ordinarily  diluted  milk  we  try  to  avoid  the  dangers  of 
excessive  carbohydrate,  on  the  one  hand,  and  of  insufficient  car- 
bohydrate, on  the  other. 

5.  The  next  step  in  our  scheme  of  prophylaxis  requires  a  care- 
ful history  and  physical  examination  of  the  patient.  If  he  be  a 
weak  child;  if  he  have  dyspepsia;  if  he  have  a  parenteral  infec- 
tion; if  he  be  suffering  from  poor  care,  we  must  be  careful  as  to 
ordering  a  high  percent  of  carbohydrate — never  over  3  percent  to 
begin  with.  If  the  examination  suggest  a  condition  of  disturbed 
balance,  or  if  the  child  be  recovering  from  an  infection,  he  needs 
increased  carbohydrate  or  at  any  rate  increased  energy.  Our  prob- 
lem in  the  latter  case  is  to  offer  the  increased  carbohydrate  to 
the  body  in  such  a  way  as  not  to  endanger  the  intestine. 

How  shall  we  make  mixtures  to  avoid  intestinal  complication? 
Gentlemen,  this  sounds  compUcated,  but  it  is  extremely  simple. 
There  is  nothing  to  it.  You  may  banish  from  your  minds  any 
worries  regarchng  the  difficulties  of  infant  feeding.  It's  the 
simplest  branch  of  pediatrics!  Simplicity  is  our  motto,  and, 
indeed,  so  simple  is  our  method  that  any  novice  can  use  it  suc- 
cessfully. To  illustrate:  In  our  stomachs  a  great  quantity  of 
hydrochloric  acid  is  secreted  daily,  but  this  acid  is  very  dilute. 
The  same  total  quantity  in  concentrated  form  would  be  deadly. 
So  it  is  with  milk.  Train  yourselves  to  think  in  terms  of  con- 
centrations— the  more  dilute  the  mixture,  the  less  injurious  to 
the  intestinal  tract  and  to  the  body  tissues  after  its  absorption. 

1.  For  the  first  four  weeks  we  use  one  part  milk  and  two  parts 
water — one-third  milk. 

2.  During  the  second  month  we  use  equal  parts  of  milk  and 
water — one-half  milk. 

3.  From  the  beginning  or  middle  of  the  third  month  we  use 
two  parts  milk  and  one  part  water — two-thirds  milk. 

In  these  mixtures,  as  the  strength  of  the  milk  is  weakened, 
we  must  offer  additional  food,  and  preferably  one  element  rather 
than  two.  This  is  done  best  by  adding  carbohydrate  in  non- 
fermentable  form,  such  as  dextri-maltose,  etc.  We  use  ap- 
proximately 3  percent  the  first  time  we  see  the  child,  and,  de- 
pending upon  the  reaction,  increase  gradually  to  5. 

To  illustrate :  Suppose  we  saw  for  the  first  time  a  normal  baby 
of  one  month.     We  would  say:  This  child  shall  receive  a  con- 


ARTIFICIAL   FEEDING   OF   THE   NORMAL   INFANT  263 

centration  of  one-half  milk.     He  drinks  roughly  20  ounces  a  day, 
so  we'll  order — 

Milk 10  ounces 

Water 10      " 

Add  3  percent  of  dextri-maltose  or,  roughly,  five  teaspoons. 
Boil  for  one  minute,  and  divide  into  seven  bottles  of  about 
23^  ounces  each. 

If  the  child  were  three  and  one-half  months  old,  we'd  say: 
He  can  tolerate  a  concentration  of  two-thirds  milk  and  drinks 
a  quart  a  day,  so  we'll  order — 

Milk 20  oimces 

Water 11       " 

Add  3  percent  of  dextri-maltose,  or  about  eight  teaspoons. 
Boil  and  divide  into  five  bottles  of  six  oimces  each. 

Don't  take  these  mixtures  as  final;  simply  make  up  one  on 
such  principles  and  then  adapt  it  to  the  baby.  Some  of  our 
Chicago  pediatricians  make  practical  application  of  these  prin- 
ciples in  a  slightly  different  way.  During  the  first  few  months 
they  order  slightly  greater  concentrations  of  milk  than  the  above 
and  avoid  disturbance  from  the  concentrated  whey  by  keeping 
the  carbohydrate  low,  i.e.,lto2  percent.  The  writer  prefers  the 
more  dilute  mixtures  with  higher  carbohydrate,  however,  for 
two  reasons: 

(a)  Constipation  of  an  obstinate  nature  is  less  fikely  to 
result  with  the  higher  carbohydrate  diet.  The  concentrated 
mixtures  with  low  sugar  lead  to  putrefactive  processes  in  the 
intestines,  and,  although  the  babies  thrive  perfectly,  probably 
using  the  protein  for  energy,  the  mothers  are  never  satisfied. 

(b)  On  the  more  concentrated  mixtures  with  lower  carbo- 
hydrate children  often  drink  greater  total  quantities  than 
those  on  the  less  concentrated,  higher  carbohydrate  diets. 
While  in  private  practice  and  infant  welfare  work,  where 
children  receive  individual  attention,  they  thrive  perfectly, 
in  hospital  wards  these  larger  quantities  frequently  induce 
vomiting. 

During  these  first  months,  what  shall  be  our  guide?  How 
shall  we  know  that  the  baby  is  doing  well?  Gentlemen,  under 
all  circumstances  let  the  weight  curve,  controlled  by  history  and 


264  INFANT   FEEDING    (CHICAGO   METHODS) 

physical  examination,  be  your  index.  If  the  baby  is  gaining  an 
average  of  five  to  seven  ounces  per  week,  and  at  the  same  time 
seems  cliiiically  well,  let  him  alone.  No  matter  though  his  stools 
be  a  little  dyspeptic ;  no  matter  if  he  have  a  slight  colic  or  slight 
diarrhea:  if  he  is  gaining  in  weight,  let  him  alone.  Your  main 
difficulty  will  be  in  treating  the  mother,  particularly  the  mother 
of  the  first  baby.  She  sits  at  the  bedside ;  in  one  hand  she  clasps 
"Mother  So  and  So's  Guide  to  Infant  Feeding,"  "based  upon 
forty  years'  experience."  She  searches  each  stool,  seizes  with 
enthusiasm  upon  any  slight  abnormaHty,  as  a  tiny  curd  of  fat 
or  a  little  mucus,  and  tells  you,  with  gloomy  joy,  that  the  food 
is  not  agreeing  with  her  baby.  Under  these  circumstances  treat 
her  as  you  will.  Tell  her  that  the  condition  is  normal;  that 
Mother  So  and  So's  book  is  old-fashioned.  Do  anything  you 
wish:  but  let  the  haby  alone. 

In  a  few  conditions  gain  of  weight  may  be  deceptive.  High 
sugar  mixtures,  as  condensed  milk,  and  particularly  mixtures 
rich  in  both  sugar  and  salt,  may  cause  water-logging  of  the  body 
and  not  an  increase  in  true  tissue  substance.  Salt  in  itself  may 
do  this  in  certain  types  of  nephritis.  In  fever  there  is  often 
acute  retention  of  water,  with  a  corresponding  gain  in  weight, 
and  again  we  know  that  a  child  may  be  gaining  nicely  and  at 
the  same  time  develop  rickets.  But  history  and  physical  exami- 
nation easily  will  preclude  such  errors,  and  knowing  the  dangers 
in  advance,  you  will  avoid  them. 

During  the  first  months  you  must  see  the  baby  or  hear  from 
the  mother  evety  few  weeks,  and  you  will  be  called  to  meet 
several  indications. 

(a)  The  child  may  vomit.  This  we  will  discuss  under  Breast 
Feeding.  But  remember  not  to  get  excited.  If  the  baby  is 
gaining,  tell  the  mother  the  vomiting  is  of  no  significance,  is 
normal,  and  make  no  change  unless  vomiting  is  very  severe, 
when  you  might  reduce  the  day's  total  feeding  by  a  few  ounces. 
If  the  baby  is  not  gaining,  it  might  be  better  to  make  no  change 
in  the  day's  total,  and  give  a  greater  number  of  feedings,  thus 
decreasing  the  amount  in  each  bottle. 

(6)  The  child  may  not  gain,  and  the  weight  curve  become 
straight  or  begin  to  drop.  The  stools  are  not  more  than  two  or 
three  per  day.     Under  these  conditions  take  the  mother  into 


ARTIFICIAL   FEEDING   OF   THE  NORMAL   INFANT  265 

your  confidence — many  mothers  really  have  more  intelligence 
than  we  imagine;  ask  if  the  baby  seems  hungry;  does  he  cry 
directly  after  finishing  his  bottle,  put  his  fingers  into  his  mouth 
between  feedings,  fret  before  the  next  bottle,  seize  it  with  avidity 
and  drain  it  rapidly?  If  so,  increase  the  total  quantity  of  food 
by  a  few  ounces,  making  no  change  in  the  proportions.  How- 
ever, if  he  seems  satisfied  with  the  quantity,  one  could  increase 
the  milk  exclusively  an  ounce  or  two,  or  the  carbohydrate  ex- 
clusively by  1  to  2  percent,  but  not  both  together. 

(c)  If  he  is  not  gaining,  does  not  seem  extremely  hungry,  and 
is  suffering  from  constipation,  then  it  is  perfectly  safe  to  in- 
crease the  proportion  of  carbohydrate  in  the  diet  to  4  or  5  per- 
cent. In  this  increase  we  have  a  true  means  of  winning  mother's 
affection.  If  our  increase  is  in  non-fermentable  carbohydrate, 
gain  in  weight  may  result,  but  the  constipation  will  persist. 
If  we  increase  with  fermentable  carbohydrate,  such  as  milk- 
sugar,  or,  more  simply,  cane-sugar,  not  only  will  gain  in  weight 
result,  but  the  resulting  fermentation  corrects  constipation. 
So,  by  striking  the  proper  balance  between  dextrin-maltose,  on 
the  one  hand,  and  fermentable  carbohydrate,  on  the  other,  we 
have  a  means  of  regulating  absolutely  the  condition  of  the  intes- 
tine and  of  bringing  joy  to  the  anxious  mother's  heart. 

(d)  If  the  w^eight  curve  straightens  out,  but  at  the  same  time 
the  stools  are  four  to  five  daily  and  fermentative,  we  are  con- 
fronted with  the  one  problem  that  may  arise  in  this  system  of 
feeding.  Dyspeptic  stools  may  be  a  symptom  of  underfeeding 
or  beginning  dyspepsia.  History  and  physical  examination  aid 
us  greatly.  If  the  child  shows  definite  symptoms  of  hunger; 
if  questioning  shows  the  mother  has  not  of  her  own  accord  made 
changes  in  the  mixture,  and  if  examination  shows  that  the  child 
looks  well,  then  it  is  safe  cautiously  to  increase  slightly  the 
amount  of  food,  noting  the  reaction.  Here  one  never  would 
increase  the  proportion  of  carbohydrate,  but  simply  the  total 
quantity,  not  changing  the  relations  of  the  different  elements. 
If,  on  the  other  hand,  the  child  shows  a  tendency  to  avoid  food, 
— these  little  children  often  are  so  much  wiser  than  we, — if 
examination  shows  him  not  looking  well,  slightly  feverish,  rings 
under  his  eyes,  and,  above  all  things,  that  mysterious  change 
in  the  skin  (the  rosy  pink  becoming  an  ashen  gray),  we  know  we 


266 


INFANT  FEEDING    (CHICAGO   METHODS) 


are  dealing  with  a  case  of  beginning  dyspepsia.  Now,  an  in- 
crease of  food  will  make  the  disturbance  worse.  Give  the  baby 
only  the  quantity  he  wishes  and  await  results. 


Iteys 

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ll 

'  1 

( 

4  OS 

2    09 

, 

r^ 

.*--' 

■"^ 

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Fig.  31. 


(e)  If,  in  connection  with  the  fermentative  stool  and  the 
child's  change  of  appearance,  the  weight  curve  definitely  starts 
to  drop,  then  we  are  dealing  with  dyspepsia,  beginning  intoxica- 
tion, or  decomposition,  and  treatment  must  be  instituted  ac- 
cordingly (Fig.  31). 

(/)  If  the  baby  isn't  gaining,  we  rarely  increase  the  day's  total 
much  over  a  quart.  Many  men  give  40  ounces  or  more.  The 
reason  I  do  not  is  that  on  the  breast  the  baby  doesn't  get  much 
over  a  quart.  A  larger  quantity  throws  an  excess  of  water  into 
the  system,  and  why  burden  the  baby's  metabolism  with  taking 
care  of  this  excess  of  fluid?  We  know  that  from  birth  on  the 
body  becomes  relatively  poorer  and  poorer  in  water.  If  at  the 
fifth  month  the  baby  ceases  to  gain,  offer  more  food  in  the  form 
of  cereal  and  a  slowly  increasing  mixed  diet.  My  own  impres- 
sion is  that  when  once  on  a  mixed  diet,  children  are  more  im- 
mune to  infections  and  to  nutritional  disturbances  than  those 
on  large  quantities  of  fluid. 

In  all  cases,  by  watching  our  weight  curve  and  by  studying 
our  little  patient  carefully,  we  can  check  most  disturbances  be- 
fore they  develop,  and  the  severe  conditions  will  be  few  indeed. 

What  is  the  advantage  of  our  method  over  the  others?  Per- 
haps its  extreme  simpUcity.  Any  method  used  by  one  trained 
in  its  application  will  be  successful.  Our  method,  however,  we 
believe  easiest  for  the  untrained  man — the  man  who  has  not 
had  time  to  work  up  his  own  technic. 


ARTIFICIAL   FEEDING   OF   THE   NORMAL  INFANT  267 

As  an  example  of  this  let  me  quote  my  experiences  in  the 
Chicago  Infant  Welfare  Society.  This  organization  was  founded 
by  private  subscription  some  six  or  seven  years  ago.  Its  object 
was  not  charity,  but  education.  The  idea  was  to  reduce  infant 
mortality,  not  by  medical  treatment,  but  by  prophylaxis;  not 
by  curing  the  sick  baby,  but  by  keeping  the  well  baby  well. 
With  this  end  in  view  one  station  was  organized  in  our  poorer 
districts.  A  physician  attended  twice  a  week.  A  salaried 
nurse  was  in  charge.  Mothers  were  urged  to  bring  their  well 
babies  for  advice  as  to  feeding,  and  during  the  intervals  between 
conferences  the  nurse  went  into  the  home  and  gave  simple  in- 
struction as  to  the  technic  of  making  the  mixtures.  No  medi- 
cine was  given ;  no  milk  supplied.  The  mothers  could  buy  their 
milk  where  and  from  whom  they  chose.  At  the  station  they 
got  nothing  but  advise. 

Gentlemen,  the  success  of  this  new  experiment  was  astound- 
ing. The  swarms  of  mothers  flocking  to  the  first  station,  the 
immediate  lowering  of  infant  mortahty,  were  all  the  evidence 
necessary  to  show  the  success  of  this  new  departure.  Under  the 
able  leadership  of  Dr.  H.  F.  Helmholz  and  Dr.  Walter  Hoffmann, 
the  organization  has  grown  in  the  last  few  years  from  the  origi- 
nal one  station  to  21.  The  numbers  of  infants  seen  in  an  after- 
noon average  about  30,  but  often  reach  50.  Wherever  a  station 
is  opened,  in  that  district  infant  mortality  drops.  This  exper- 
ience was  in  a  way  very  humiliating  to  me.  I  served  the  Society 
for  several  years  as  assistant  medical  director.  During  that 
time  I  had  ten  or  eleven  stations  under  my  charge  and  visited 
them  each  once  a  month.  I  saw  many  men  for  the  first  time 
come  to  take  charge;  saw  these  men  instructed  in  the  above 
simple  methods  of  feeding,  and  saw  these  men  in  a  very  few 
weeks'  time  obtain  just  as  successful  results  as  I  did  with  a  much 
wider  experience.  They  had  never  read  Finkelstein  or  Czerny 
or  Heubner;  but  the  results  accompUshed  were  all  that  were 
necessary.  Nothing  speaks  more  for  the  simplicity  of  our  feed- 
ing than  the  success  of  the  Infant  Welfare  Society.  True  distur- 
bances of  nutrition  rarely  arise.  The  children  become  simply 
"feeders." 

In  this  work,  gentlemen,  one  fact  has  impressed  me  most 
strongly.     That  is  the  fundamental,  the  previously  unrecog- 


268  INFANT   FEEDING    (CHICAGO   METHODS) 

nized,  but  indispensable,  services  of  our  nurses.  We,  in  the 
stations  or  in  the  dispensaries,  see  the  baby  for  a  moment  and 
write  out  a  formula  for  the  milk  mixture;  the  nurse,  however, 
goes  into  the  home  and  meets  the  true  condition.  She  sees  all 
the  great  influences  which  are  at  work, — the  accessory  aiding 
influences, — the  influences  which  constantly  are  undermining 
the  baby's  constitution  and  upsetting  our  plans.  She  instructs 
the  mother  as  to  proper  clothing;  she  teaches  that  on  a  warm 
summer's  day  it  is  unwise  to  wrap  the  baby  up  in  thick  layers, 
surround  him  with  a  pillow,  or  place  him  near  the  kitchen  stove. 
She  informs  the  mother  about  the  dangers  of  flies,  and  attempts 
in  a  simple  way  to  protect  the  child  from  these  pests.  She  shows 
how  to  bathe  the  baby.  She  dwells  upon  the  importance  of 
regularity  of  feeding;  she  demonstrates  the  proper  care  of  the 
bottle  and  the  cleansing  of  the  rubber  nipple;  she  shows  how  to 
keep  the  milk  cool  if  no  ice-box  is  available,  by  placing  the  bottle 
in  a  tub  of  cool  water;  in  short,  she  fulfils  the  indications  which 
Schlossman  so  pointedly  expressed  when  he  said,  "A  good  nurse 
can  always  overcome  the  mistakes  of  any  poor  physician." 

Gentlemen,  those  of  you  who  are  interested  in  infant  feeding, 
those  who  wish  wider  experience  in  dealing  with  nurslings,  those 
who  wish  to  do  inestimable  good  in  the  poorer  districts,  should 
attempt  to  establish  an  Infant  Welfare  Society;  and,  in  your 
own  practice,  profit  by  the  lessons  that  we  have  learned.  Where 
these  splendid  nurses  are  not  available,  be  yourselves  a  little 
more  the  nurse,  a  little  less  the  physician.  Explain  clearly  to 
the  mother  that  she  is  not  doing  her  duty  simply  by  mixing  the 
milk  in  the  proportions  you  have  suggested,  but  that  she  must 
fulfil  all  the  other  requirements  which  are  so  essential  to  the 
baby's  general  health,  and  without  which  any  system  of  feeding 
will  fail.  If  you  will  only  lay  sufficient  emphasis  upon  the 
nursing  care  of  your  infants,  the  feeding  will  almost  take  care 
of  itself. 

Have  we  spoken  the  last  word?  Is  our  method  going  to  last? 
I  do  not  think  so.  New  advances  constantly  will  be  made — 
ones  we  shall  adopt,  no  matter  what  their  source.  I  believe 
that  we  have  mastered  the  art  of  guiding  food  past  the  intestinal 
tract  into  the  body,  but  rather  than  rest  upon  our  laurels  we 
must  arise  to  attack  newer  and  more  intricate  problems — ones 


ARTIFICIAL   FEEDING    OF   THE   NORMAL  INFANT  269 

which  loom  ominously  before  us.  Are  our  combinations  those 
best  adapted  to  meet  the  demands  of  the  body?  In  years  to 
come  we  may  learn  that  boiled  milk  has  produced  some  hidden, 
undiscovered  damage.  We  have  learned  that  high  carbohy- 
drate, fed  exclusively  or  in  combination  with  high  salts,  fills  the 
tissues  with  water  but  does  not  satisfy  their  hunger.  Some 
evidence  shows  that  children  fed  with  no  fat  in  the  diet  may  at 
times  possess  a  decreased  immunity  to  infection.  We  may 
learn  in  time  that  our  moderate  reduction  of  fat,  our  slight  in- 
crease of  carbohydrate,  though  passing  the  intestine  easily  and 
safely,  may  not  have  been  a  combination  best  adapted  for  the 
body  tissues.  Only  years  of  study  and  observation  will  an- 
swer these  questions.  The  physiologist,  Friedenthal,  recently 
has  devised  a  mixture  in  which  the  salt  proportions  are  identical 
to  those  of  breast  milk.  In  this  mixture  fat  and  carbohydrate 
may  be  given  in  the  same  relations  as  in  breast  milk,  with  Uttle 
evidence  of  intestinal  disturbance.  This  is  again  a  splendid 
step:  a  means  of  introducing  fat  and  carbohydrate  into  the 
tissues  in  the  same  proportions  as  they  exist  in  breast  milk,  and 
with  no  danger  +^  the  intestinal  tract,  but  is  as  yet  somewhat 
impracticable. 

IJntil  these  indications  can  be  met  practically  and  simply; 
until  we  can  introduce  to  the  tissues  food-stuffs  in  the  same  pro- 
portions as  they  exist  in  breast  milk  without  in  any  way  im- 
pairing digestive  and  assimilative  functions,  we  believe  that  our 
method  of  feeding  is  the  most  feasible.  It  is  easily  employed, 
seems  to  satisfy  the  mothers,  seems  to  provide  for  the  growth 
of  healthy,  thriving,  happy  babies,  who  look  well  and  strong  and 
appear  smiling  and  contented,  and,  first  and  foremost,  it  answers 
the  requirements  of  simplicity. 


LECTURE  IX 
BREAST  FEEDING 

I  have  neglected  the  subject  of  breast  feeding  until  now  be- 
cause often  it  becomes  necessary  to  supplement  the  breast  with 
the  bottle.  If  we  have  mastered  the  art  of  prescribing  artificial 
mixtures,  then  difficulties  with  supplementary  feeding  will  be 
very  slight  indeed. 

It  is  not  necessary  to  emphasize  the  importance  of  breast 
feeding.  You  know  that  breast  milk  is  the  natural  food.  You 
know  that  the  breast-fed  infant  is  more  immune  to  infectious 
disease  than  is  the  artificially  fed.  You  know  that  mortaUty  is 
much  less  among  breast  fed  than  among  bottle  babies.  When- 
ever there  is  any  possibihty  of  offering  breast  milk,  by  all  means 
do  so. 

General  contraindications  to  breast  feeding  are  few.  As 
you  know,  tuberculosis  in  the  mother  almost  unanimously  is 
agreed  a  distinct  one,  but  even  against  this  some  voices  have 
been  raised.  Tubercle  bacilh  have  never  definitely  been  dem- 
onstrated in  human  milk,  and  some  men  claim  if  the  mother, 
during  nursing,  will  protect  the  baby  from  her  coughing,  that 
tuberculosis  is  a  contraindication  only  from  her  own  standpoint 
and  not  from  that  of  the  child.  This,  however,  is  the  opinion 
of  a  few,  but  I  give  it  to  show  that  even  against  the  most  ortho- 
dox of  all  contraindications  objections  have  been  filed.  I  be- 
lieve, though,  that  the  consensus  of  opinion  makes  tuberculosis 
of  the  mother  a  contraindication  to  nursing,  not  only  from  her 
own  standpoint,  but  also  from  that  of  the  child. 

Severe  constitutional  diseases,  such  as  malignancy  and  epi- 
lepsy, are,  of  course,  contraindications. 

As  regards  acute  infectious  disease,  such  as  typhoid,  scarlet, 
diphtheria,  etc.,  opinion,  particularly  in  European  clinics,  is 
becoming  more  and  more  tolerant.     The  newborn  has  consider- 

270 


BREAST   FEEDING  271 

able  immunity  to  infectious  disease.  Again,  very  few  patho- 
genic bacteria  have  been  demonstrated  in  breast  milk,  and  the 
theoretical  objection  that  toxins  are  excreted  may  be  met  with 
the  theoretical  answer  that  antitoxins  also  will  pass  to  the  child. 
Even  in  diphtheria,  if  the  child  be  properly  immunized,  breast 
feeding  is  permitted. 

These  opinions  of  the  European  men  may  seem  rather  radical 
to  you.  I  give  them,  however,  to  emphasize  the  importance  in 
which  breast  feeding  is  held,  and  to  show  that  most  contraindica- 
tions are  those  raised  in  consideration  of  the  mother  rather  than 
the  infant.  Even  in  erysipelas,  where  a  superficial  infection  of 
the  breast  makes  it  possible  for  organisms  to  pass  to  the  milk, 
this  may  be  drawn  off,  boiled,  and  then  offered  to  the  baby. 

Syphihs,  as  you  know,  is  an  indication,  rather  than  a  contra- 
indication. Whether  the  syphihtic  woman  be  mother  of  an 
apparently  well  baby,  or  whether  an  entirely  well  woman  be 
mother  of  a  syphilitic  baby,  in  all  cases  we  should  insist  upon 
breast  feeding,  for  in  both  these  conditions  we  beheve  that 
mother  and  child  are  alike  infected. 

Some  difficulties  arise,  however,  from  local  changes  in  the 
mother's  breasts.     Perhaps  two  are  important: 

1 .  Retracted  nipples  make  much  trouble,  cause  great  anxiety 
to  the  mother,  and  to  considerable  extent  handicap  the  nursing. 
In  many  cases,  however,  if  the  mother  practises  patience,  these 
difficulties  can  be  overcome.  Instead  of  surrendering  in  des- 
pair, simply  tell  her,  "Yes,  it's  going  to  be  hard  for  the  baby  to 
nurse,  but  if  you  practise  patience  and  perseverance,  after  a 
week  or  two  he  may  learn  to  take  the  breast."  Patience  and 
perseverance  are  the  requisites  necessary,  and  after  a  week  or 
two  of  conscientious  work  the  mother  may  be  able  to  educate 
her  child  to  nurse  from  nipples  that  previously  seemed  hopeless. 
Application  of  a  breast-pump  between  nursing  periods  aids  in 
dra"«ang  them  out. 

2.  Erosions  and  fissures  are  extremely  disagreeable.  By  the 
pain  inflicted  upon  the  mother  they  make  nursing  a  very,  great 
burden  indeed.  The  variety  of  treatments  offered  is  of  itself 
sufficient  evidence  of  the  inefficiency  of  any  particular  method. 
Medicaments  suggested  are: 

.  (a)  The  use  of  a  cotton  swab  saturated  with  1  to  2  percent 


272  INFANT   FEEDING    (CHICAGO   METHODS) 

silver  nitrate  solution,  and  laid  upon  the  fissure  for  a  minute 
once  during  the  day. 

(6)  The  following  prescription  of  the  French  is  one  highly  rec- 
ommended by  Langstein  and  Meyer.  Personally,  I  have  had 
no  experience  with  it,  but  I  give  it  upon  their  recommendation. 
The  technic  is  as  follows:  Wash  the  nipple  after  nursing,  and 
apply  the  following  mixture  on  sterile  gauze: 

Tincture  of  benzoin 12.0 

Sodium  borate 8.0 

Glycerin 20.0 

Rose-water 40.0 

Cover  with  oiled  silk  or  gutta-percha  and  bandage.  Before 
the  next  nursing  wash  off  with  lukewarm  boiled  water. 

A  valuable  point  in  treating  these  fissures  is  the  use  of  a  mild 
local  anesthetic  ointment.  A  5  percent  salve  of  anesthesin 
appUed  to  the  fissures  just  before  nursing  is  a  great  relief  to  the 
mother.  Anesthesin  is  not  poisonous  to  the  child,  and  is  very 
acceptable  to  the  mother  on  account  of  the  rehef  from  the  severe 
pain.  In  order  to  give  the  painful  nipple  as  much  rest  as  pos- 
sible, longer  feeding  intervals  should  be  employed ;  indeed,  one 
might  substitute  a  bottle  for  one  nursing.  Nipple-shields  too 
are  of  great  value.  The  very  best  of  these  is  a  large  one,  made  of 
pure  rubber,  covering  almost  the  entire  breast. 

Difficulties  with  nursing  from  the  standpoint  of  the  child  are 
not  many.  A  cleft-palate  or  harelip  is  to  be  considered.  These 
handicaps,  like  the  retracted  nipple,  often  can  be  overcome  by 
patient,  conscientious  work  of  the  mother.  Many  cases  which 
seem  hopeless  at  first,  after  a  week  or  two  of  devoted  care  may 
learn  in  some  way  to.  obtain  milk  from  the  breast. 

Other  difficulties,  such  as  a  neuropathic  constitution  of  the 
child,  we  shall  consider  in  the  next  lecture. 

As  regards  the  entrance  of  milk  into  the  breast,  this  occurs 
between  the  first  and  eighth  days — usually  about  the  fourth. 
Often,  however,  it  is  delayed,  and  you  are  asked  by  all  con- 
cerned, "Can  we  hasten  it?" 

Gentlemen,  there  is  one,  and  only  one,  lactagogue  you  may 
use  with  any  degree  of  assurance,  and  that  is  the  nursing  infant. 
The  only  stimulus  to  a  breast  is  one  arising  from  this  source. 


BREAST   FEEDING  27S 

Wet-nurses  in  European  clinics  sometimes  nurse  four  or  five 
babies,  and  often  secrete  two  to  three  quarts  of  milk  a  day: 
the  greater  the  stimulus  to  the  breast,  the  greater  the  response. 
And  so,  gentlemen,  to  hasten  the  entrance  of  milk  into  the 
lagging  breasts,  urge  the  frequent  and  regular  application  of  the 
infant.  Of  course,  if  the  mother  believes  that  any  particular 
medicine  or  any  particular  drink  is  going  to  help  her,  or  does 
help  her,  by  all  means  don't  discourage  her.  Do  anj'thing  you 
can  to  put  her  mind  at  ease,  and  at  the  same  time  to  keep  her 
in  the  best  physical  condition.  If  the  baby  does  not  nurse  very 
vigorously,  you  may  use  a  breast-pump  also;  but  this,  in  con- 
nection with  massage,  electricity,  and  all  other  artificial  aids,  is 
infinitely  less  efficient  than  the  normal  natural  method. 

If,  in  spite  of  frequent,  regularly  repeated  applications  of  the 
babe  to  the  breast,  the  milk  still  delays,  how  long  shall  we  wait? 
Safely,  a  few  days.  During  this  time  we  must  be  very  careful 
not  to  entirely  appease  the  baby's  appetite  with  artificial  food. 
We  must  keep  him  hungry.  We  want  him  to  tug  good  and  hard 
at  the  breast,  and  therefore,  during  this  time,  we  offer  only  a 
little  water  or  weak  tea.  By  this  method  we  can  accelerate  the 
appearance  of  the  milk.  However,  gentlemen,  don't  focus  your 
attention  so  carefully  upon  the  mother  that  you  forget  the  child. 
Don't  let  your  zeal  for  hunger  lead  you  into  the  greater  error 
of  letting  the  child  suffer  from  too  much  hunger.  In  all  these 
cases,  as  I  have  repeated  over  and  over,  our  index  is  the 
baby's  weight  curve.  The  physiologic  loss  of  weight  during  the 
first  few  days  amounts  to  from  one-half  to  one  pound.  If  the 
child  shows  no  tendency  to  recover,  or  if  he  continues  to  lose, 
we  must  heed  this  danger-signal  and  direct  our  attention  more 
to  the  babe  and  less  to  the  mother.  We  must  put  him  to  the 
breast  more  frequently,  using  both  breasts  if  necessary,  or  if 
this  is  impossible,  add  a  bottle  to  the  diet.  We  must  never  for 
a  moment  allow  the  hunger  to  develop  weakness,  for  if  the  child 
becomes  too  weak  to  nurse  properly,  we  defeat  our  own  purpose. 

Among  the  laity  the  general  opinion  is  that  breast  milk  is 
influenced,  as  regards  quantity  and  quality,  by  many  different 
factors — by  diet,  by  medication,  by  nervous  influence''.  As  a 
matter  of  fact,  accurate,  scientific  experiments  showing  changes 
in  breast  milk  are  very  few  indeed.  You  must  remember  that 
18 


274  INFANT   FEEDING    (CHICAGO   METHODS) 

the  amount  of  the  individual  ingredients  secreted  during  the 
individual  nursing  varies.  Fat  is  in  small  amount  at  the  begin- 
ning, and  increases  toward  the  end.  To  get  experiments  not 
subject  to  criticism  one  must  analyze  twenty-four-hour  speci- 
mens of  breast  milk. 

Experiments  which  will  withstand  searching  criticism  are 
few,  but  those  that  have  been  made  suggest  that  nervous  and 
psychic  factors,  pregnancy  and  menstruation,  positively  have 
no  effect  upon  the  quality  of  the  breast  milk.  Undoubtedly 
children  show  disturbance  at  such  times,  particularly  during  the 
menstrual  period,  but  our  present  observations  tend  to  show 
that  these  disturbances  are  due  to  changes  in  quantity  rather  than 
quality  of  breast  milk.  Less  milk  is  secreted,  the  child  is  hun- 
gry, becomes  peevish,  irritable,  and  fretful,  and  the  natural 
conclusion  is  that  the  quality  of  the  milk  is  changed — that  the 
milk  is  not  agreeing  with  him.  As  far  as  we  know  now,  how- 
ever, there  is  only  one  definite  change,  and  this  usually  a  dimi- 
nution  of  the  total  secretion. 

As  regards  the  influence  of  diet,  we  despair  more  and  more. 
No  one  in  experiments  devoid  of  criticism  has  shown  that  he  can 
control  at  will  the  quantity  or  quaUty  of  breast  milk  by  change  of 
diet.  Many  of  the  statements  you  read  as  to  the  efficiency  of 
diet  are  based  upon  only  the  most  superficial  investigations. 
There  is  one  exception,  perhaps,  this  being  with  fat.  In  under- 
fed, badly  nourished  women,  high  fat  feeding  at  times  seems  to 
increase  the  fat  in  the  milk  secreted.  There  is  some  doubt, 
however,  as  to  whether  this  influence  is  exerted  also  in  well- 
nourished  women.  Probably  it  will  hold  absolutely  true  only 
in  the  undernourished. 

We  are  in  the  same  position  as  regards  medication.  Every 
drug  in  the  pharmacopoeia  at  some  time  or  other  has  been  tried. 
Every  one  in  turn  has  been  given  up.  The  latest  is  pituitrin. 
This,  in  definite  physiological  experiment,  will  increase  the 
amount  of  milk  excreted  in  a  given  time,  but  again  must  we  be 
disappointed.  Most  recent  observations  show  that  it  acts  upon 
the  smooth  muscle-fibers,  causes  them  to  contract,  thus  forcing 
the  milk  more  rapidly  from  the  breast,  but  that  it  in  no  way 
affects  the  total  secretion. 

There  are  two  ways  by  which  we  may  affect  the  supply  of 


BREAST   FEEDING  275 

breast  milk.  Undoubtedly  one  is  by  building  up  the  general 
nutrition  of  the  mother — good  hygiene,  good  food,  fresh  air, 
and  plenty  of  exercise.  Many  nursing  mothers  are  lax  in  this 
respect.  Besides  hygiene,  there  is  the  aforesaid  suggestion, 
namely,  the  use  of  a  hungry,  healthy,  strong  child.  So  much 
difficulty,  however,  attends  this  in  private  practice  that  it  is 
really  just  as  satisfactory  to  add  a  supplementary  bottle  after 
each  feeding  from  the  start. 

As  a  matter  of  fact,  in  most  disturbances  upon  the  breast  the 
following  scheme  is  satisfactory.  Make  up  your  mind  that 
breast  milk  is  alwaj'-s  all  right  in  quality.  Make  up  your  mind 
that  the  only  difficulties  arising  from  breast  feeding  are  those  of 
quantity.  Treat  the  mother  as  you  will  to  put  her  mind  at 
rest,  but  from  your  own  standpoint  conduct  your  treatment 
along  the  lines  of  correction  of  the  amount,  and  if  you  keep  your 
child  on  four-hour  feedings,  this  correction  will  be  one  usually 
for  underfeeding,  rather  than  overfeeding. 

You  see  why  in  relatively  well-nourished  babies  who  are  not 
gaining  on  the  breast  I  like  to  wait  a  week  or  so  without  the 
supplementary  bottle.  I  reason  that  may  be  from  nervous  fac- 
tors or  constitutional  change  there  has  been  a  temporary  dimi- 
nution in  the  secretion,  and  that,  after  a  week  or  two,  this  will 
right  itself.  However,  where  the  condition  has  lasted  longer, 
out  of  consideration  for  the  child  we  are  justified  in  no  further 
delay. 

Just  a  few  words  about  the  technic  of  nursing,  because  errors 
in  technic  sometimes  are  responsible  for  many  disturbances. 
Some  men  would  not  place  the  newborn  to  the  breast  at  all 
during  the  first  twenty-four  hours;  others  would  every  six 
hours.  As  long  as  one  keeps  up  the  supply  of  fluid,  these  dif- 
ferences in  technic  are  of  slight  importance.  Personally,  I 
believe  application  to  the  breast  is  better,  as  it  stimulates  secre- 
tion of  milk  and  possibly  also  uterine  contractions. 

Question  (by  Dr.  Summerell  of  China  Grove). — Doctor,  have 
you  had  enough  experience  in  the  country  to  have  seen  new- 
born pigs? 

Answer. — No;  my  personal  experience  in  that  direction  is 
limited. 

Question. — Well,  the  minute  pigs  are  born  they  make  for  the 


276  INFANT   FEEDING    (CHICAGO   METHODS) 

breast  and  nurse  right  away.  Don't  you  think  it's  a  good  idea 
in  our  treatment  to  follow  the  lead  of  nature? 

Answer. — Yes,  that's  an  interesting  point,  I  think  if  we 
physicians  had  more  experience  with  country  life  it  would  be 
better  for  us.  I  should  consider  that  observation  as  valuable 
evidence  in  favor  of  putting  the  child  to  the  breast  during  the 
first  day. 

As  regards  rigid  disinfection  of  the  breasts,  our  ideas  are 
changing  more  and  more.  Where  the  mother  practises  ordi- 
nary cleanliness,  application  of  strong  chemicals  to  the  nipple 
is  absolutely  uncalled  for.  Of  course,  in  very  poor  districts, 
where  the  breasts  are  caked  with  dirt,  they  must  be  washed 
thoroughly;  but  in  ordinary  private  practice  cleansing  with  a 
little  cotton  and  lukewarm  water  is  all  that  is  necessary.  If  the 
mother  be  of  the  modern,  scientific  type  and  wishes  something 
more  fashionable  and  antiseptic,  use  a  little  boric  solution. 
Personally,  however,  I  believe  the  use  of  strong  antiseptics  a 
frequent  cause  of  painful,  fissured  nipples. 

Question  by  Dr.  Summerell. — In  the  cases  of  our  poor  patients, 
where  the  mother's  work  keeps  her  all  day  long  in  the  fields, 
where  underclothing  is  changed  infrequently,  and  where  cloth- 
ing is,  of  course,  saturated  with  perspiration,  where  absolutely 
no  care  of  the  body  is  taken  before  the  baby  nurses — in  such 
cases,  doctor,  do  you  advise  some  sort  of  application  to  the 
nipples? 

Answer. — ^Where  the  breasts  and  nipples  are  dirty,  of  course 
they  should  be  cleaned,  but  the  best  means  for  this  process  is 
ordinary  soap  and  water. 

Question. — Do  you  beUeve  the  offensive  odor  of  the  clothes 
in  such  cases  would  interfere  with  the  baby's  appetite  or  pre- 
dispose to  disturbance? 

Answer. — ^The  influence  of  bad  odors  and  bad  air  upon  a 
nursling's  appetite  is  open  to  dispute.  I  believe,  however,  that 
most  men  think  this  influence  unimportant. 

How  often  shall  we  put  the  baby  to  the  breast?  The  same 
rules  apply  as  to  the  bottle  baby. 

How  long  shall  we  allow  the  baby  to  nurse?  Until  he  is 
satisfied,  and  this  requires  from  fifteen  to  twenty  minutes. 
The  first,  five  are  the  most  important,  for  in  these  five  the  baby 


BREAST   FEEDING  277 

gets  the  greatest  amount  of  milk.  You  easily  can  tell,  gentle- 
men, when  he  is  satisfied  by  the  cessation  of  the  swallowing 
sound.  When  he  is  hungry,  he  nurses  and  swallows  constantly. 
When  he  ceases  to  swallow  and  hes  playing  idly  with  the  nipple, 
he  has  had  enough.  If  he  has  emptied  the  breast  thoroughly 
and  still  is  not  satisfied,  we  either  order  an  increase  in  the  num- 
ber of  feedings  or  put  him  to  both  breasts.  But  in  the  latter 
case  we  must  be  perfectly  sure  that  the  first  breast  has  been 
emptied  thoroughly.  A  child  is  easily  spoiled,  and  if  the  second 
breast  awaits  him,  often  will  not  thoroughly  empty  the  first. 
Of  course,  th^  reduction  of  the  stimulus  will  cause  reduction  of 
the  amount  of  milk  secreted. 

One  httle  point  of  technic  often  is  overlooked — a  point  of 
considerable  value,  even  though  used  by  our  grandmothers. 
You  remember  our  grandmothers  used  to  interrupt  the  nursing 
at  intervals  to  place  the  baby  so  that  the  abdomen  was  against 
grandmother's  shoulder.  Then  she  would  pat  him  on  the  back 
until  he  belched  up  some  air.  In  the  younger  daj's  of  pediatrics 
any  practice  interfering  with  the  quiet  of  nursing  was  rejected. 
Recently,  however,  we  are  learning  that  there  is  much  truth  in 
grandmother's  ad\ace.  If  you  hold  a  baby  when  nursing  in 
front  of  the  fluoroscope,  you  will  see  that  he  frequently  swallows 
air.  A  large  bubble  collects  in  the  upper  part  of  the  stomach. 
This  interferes  with  the  proper  filling  of  the  stomach,  prevents 
his  getting  sufficient  food,  often  makes  him  vomit,  and  may 
cause  colic.  If  you  break  the  nursing  interval  everj'  few  min- 
utes and  pat  the  child  upon  the  back,  as  our  grandmothers  did, 
he  belches  up  air,  the  tension  in  his  stomach  is  relieved,  and  he 
nurses  with  renewed  vigor.  Many  perplexing  difficulties  with 
breast  feeding  are  overcome  by  this  simple  bit  of  advice. 

In  instructing  the  mother  as  to  nursing,  tell  her  the  baby  does 
better  if  he  has  not  only  the  nipple,  but  also  a  little  of  the  areola 
in  his  mouth. 

How  do  we  know  when  the  baby  is  doing  well — if  he  is  getting 
sufficient  food?  The  best  index,  gentlemen,  is  his  weight.  If 
he  gains  on  an  average  of  about  six  ounces  a  week,  no  fault  can 
be  found  with  his  nutrition. 

Dr.  Summerell  asks  how  often  it  is  advisable  to  weigh  the 
baby  as  a  routine. 


278  INFANT   FEEDING    (CHICAGO   METHODS) 

Answer. — ^The  oftener  the  better.  I  should  say  at  the  very 
least  once  or  twice  a  week. 

Dr.  Summerell. — That  is  all  right,  doctor,  but  in  our  country 
practice  the  parents  have  no  scales.  Have  you  any  idea  as  to 
the  feasibility  of  a  portable  scales? 

Answer. — One  of  the  men  of  the  Children's  Memorial  Hospital 
at  home  (Dr.  Spicer)*  has  devised  an  ingenious  scales.  I  have 
had  no  experience  with  it  myself,  but  from  his  description  it 
sounds  quite  practicable. 

What  shall  be  the  diet  of  a  nursing  mother?  As  far  as  we 
know  the  nursing  mother  may  eat  absolutely  anything  that 
makes  her  happy  and  contented.  We  may  disregard  totally  in 
this  respect  the  mandates  of  our  grandmothers.  If  the  nursing 
mother  likes  vinegar  and  it  agrees  with  her,  let  her  have  it. 
Whatever  she  craves,  whatever  she  can  digest,  whatever  pleases 
her  and  makes  her  happy  and  contented,  she  shall  have.  Our 
sole  desire  in  regulating  her  diet  shall  be  to  fulfil  three  require- 
ments: 

(a)  She  must  have  enough  food.  Many  a  poor  woman  does 
not  secrete  a  good  supply  of  milk  because  she  herself  is  starving. 

(6)  The  food  must  be  digestible.  The  nature  of  the  food  de- 
pends upon  the  mother's  social  condition  and  her  tastes,  but 
anjrthing  that  she  can  digest  she  may  eat. 

(c)  Lastly,  we  must  gratify  her  thirst.  Langstein  and  Meyer 
dwell  upon  this  point,  which  seems  to  me  a  very  important  one. 
The  mother  normally  secretes  about  a  quart  of  milk  a  day. 
Thus  she  excretes  almost  a  quart  of  water  more  than  normally. 
You  see,  then,  that  she  has  every  reason  to  be  thirsty.  Here  is 
where  many  mistakes,  even  by  well-educated  physicians,  are 
made.  The  physician  takes  advantage  of  this  thirst  to  force 
extra  food.  The  mother  does  not  need  extra  food  at  this  time, — 
her  appetite  is  taking  care  of  that,— but  she  needs  fluid.  This 
should  be  given  as  water,  tea,  broth,  or  thin  soup.  How  wrong 
it  is  to  take  advantage  of  her  need  of  fluid  by  throwing  into  her 
body  a  great  excess  of  starches,  such  as  are  contained  in  thick 
soups  and  gruels.  She  does  not  need  this  excess  of  food  pro- 
vided she  is  getting  her  meals  normally :  she  needs  simply  water. 

Qitestion  by  Dr.  Gilmer. — Doctor,  if  a  baby  is  four  months  old, 
*  Amer.  Jour.  Dis.  Children,  January,  1915,  p.  70. 


BREAST    FEEDING  279 

could  you  offer  him  milk  from  a  mother  of  a  newborn?  What 
is  the  present  idea  as  regards  feeding  children  milk  of  a  mother 
whose  child  is  so  much  younger? 

Answer. — As  far  as  we  know  now,  such  considerations  are  im- 
material. Breast  milk  is  the  ideal  food,  and  is  infinitely  better 
than  any  other  food  that  can  be  offered,  no  matter  how  young 
or  old  the  other  baby  may  be. 


LECTURE  X 
DISTURBANCES  IN  THE  BREAST  FED 

Gentlemen,  disturbances  of  the  breast  fed  also,  we  prefer  to 
consider  as  disturbances  of  nutrition.  Just  as  in  the  artificially 
fed  child,  the  symptoms  arising  are  many  more  than  those  of 
simply  local  gastro-intestinal  irritation.  The  skin,  the  nervous 
system,  the  decreased  immunity  to  infections,  above  all,  the 
weight  curve,  show  that  involvement  is  general. 

Just  as  in  the  artificially  fed  baby,  we  find  vomiting,  diarrhea, 
or  constipation.  When  these  exert  no  influence  upon  the  weight 
curve,  we  are  acting  wisely  if  we  let  the  baby  alone.  However, 
as  you  once  took  me  to  task  as  regards  the  practical  importance 
of  these  subjects,  just  a  few  words  about  them. 

VOMITING 

If  the  babe  is  brought  for  vomiting,  the  first  thing  to  estabhsh 
is  the  duration  of  the  symptom.  Is  it  an  acute  attack  or  has  it 
been  present  for  a  long  time?  Acute  vomiting  may  be  due  to 
infections,  enteral  or  parenteral,  may  be  associated  with  dis- 
turbances of  nutrition  or  metaboUc  disorders,  may  be  due  to 
nervous  factors  which  are,  as  yet,  not  clear  to  us,  and,  of  course, 
in  older  children  may  follow  the  conventional  cucumber-water- 
melon mixture.    Often  it  is  due  to  too  much  fat. 

Chronic  vomiting  may  be  associated  with  chronic  disturbances 
of  nutrition,  such  as  decomposition,  may  occur  even  in  inanition, 
may  be  associated  with  a  so-called  neuropathic  constitution 
(which  we  shall  discuss  in  a  moment),  and  may  be  due  to  pyloro- 
spasm  or  pyloric  stenosis. 

Treatment. — In  our  treatment,  however,  we  must  adopt  the 
same  attitude  that  we  have  to  the  stool.  Vomiting  is  simply  a 
symptom  and  must  be  made  subservient  to  the  condition  of  the 
baby  as  a  whole.  If  the  baby  is  gaining;  if  he  is  well  and  happy 
and  contented,  by  all  means  let  him  alone.  Keep  your  eyes  open 
for  errors  in  technic  of  nursing,  such  as  overfeeding,  irregular 

280 


DISTURBANCES    IN   THE    BREAST   FED  281 

feeding,  neglect  of  patting  him  on  the  back,  and  too  rapid  feed- 
ing; but  frequently  vomiting  persists  in  spite  of  perfect  and  un- 
impeachable routine.  If  so,  the  disturbance  is  due  probably 
to  the  baby,  the  fault  lying  with  a  hyperesthetic  mucous  mem- 
brane or  to  faulty  reflexes.  No  matter  what  be  the  underlying 
cause,  if  the  bab}^  is  thriving,  if  he  is  happy,  contented,  and  satis- 
fied, take  the  mother  into  your  confidence :  tell  her  this  condition 
occurs  so  frequentlj''  as  to  be  considered  almost  normal;  and 
explain  that  from  the  third  to  the  sixth  month  it  will  disappear. 

On  the  other  hand,  if  the  baby's  nutrition  is  suffering,  we 
must  take  notice.  Acute  attacks  wall  disappear  upon  treat- 
ment of  the  underlying  cause,  and  require  httle  actual  treatment 
of  the  vomiting  except  in  older  children  who  have  devoured  im- 
possible food-mixtures.  For  them  a  good  stomach  washing  and 
a  dose  of  castor  oil  wall  be  a  cure. 

In  the  chronic  vomiting  also  we  attempt  to  treat  the  funda- 
mental cause,  as  in  nutritional  disturbances.  Pyloric  stenosis 
may  require  operation.  The  spastic  vomiting  of  neuropaths, 
usually  considered  a  pylorospasm,  may  be  influenced  by — 

(a)  Increasing  the  number  of  feedings  and  thus  decreasing 
the  quantity  in  each. 

(b)  Reduction  of  the  fat,  and  offering  as  a  substitute  Keller's 
Malt  Soup  or  a  buttermilk  mixture. 

(c)  Anesthesin  or  novocain,  1/60  grain  before  meals. 

(d)  Tincture  of  belladonna,  one  or  two  drops  with  a  few  drops 
of  paregoric  before  meals.     I  have  found  this  very  satisfactory. 

(e)  Sodium  citrate,  1  to  2  percent;  one  dram  in  each  bottle 
has  been  recommended  by  the  French. 

Prolonged  boiling  of  the  milk  for  some  minutes  may  be  very 
successful. 

But  in  all  cases  don't  do  too  much.  Sometimes  all  that  is 
necessary  is  to  reduce  the  total  quantity  and  make  up  for  the 
decrease  of  food  value  by  an  increase  in  concentration. 


ABNORMAL  BOWEL  MOVEMENTS 

(a)  In  reading  text-books  you  learn  that  the  stool  of  the  nor- 
mal breast-fed  baby  is  soft,  homogeneous,  pasty,  yellow^,  and 
smooth.     This  undoubtedly  is  a  normal  stool.     But,  gentle- 


282  INFANT   FEEDING    (CHICAGO   METHODS) 

men,  if  you  examine  a  great  number  of  breast-fed  babies  you 
find  that  the  stools  are  green,  sUghtly  watery,  somewhat  acid, 
and  contain  mucus  and  curds.  These  occur  more  frequently, 
or  at  any  rate  fully  as  frequently,  as  those  described  in  the  text. 
In  spite  of  this  apparent  abnormahty  the  hahy  thrives,  gains 
persistently,  is  happy,  contented,  and  satisfied.  Under  such 
circumstances,  why  these  stools  are  not  to  be  considered  normal 
I  do  not  know. 

The  cause  of  them  is  not  certain.  It  may  be  intestinal  fer- 
mentation; it  may  be  a  neuropathic  constitution — probably 
both.  But  as  long  as  the  baby  is  happy,  contented,  and  gain- 
ing, let  him  alone,  and  instruct  the  mother  that  this  stool  is 
absolutely  normal.  Tell  her  that  it  will  correct  itself  by  the  third 
to  sixth  month.  If  it  does  not,  we  can  be  of  service  in  a  way 
to  be  mentioned  later. 

(6)  Constipation. — In  discussing  the  constipation  that  occurs 
independent  of  nutritional  disturbance,  let  me  present  an  idea 
of  my  own.  I  present  this  to  you  purely  as  an  idea,  not  as  a 
fact — one  which  you  may  in  your  leisure  moments  consider, 
but  not  necessarily  believe.  For  my  own  purpose  I  divide  con- 
stipation into  two  types:  these  you  probably  will  not  find  in 
text-books;  but  this  arbitrary  classification  has  been  of  great 
value  to  me. 

(1)  The  first  I  call  pseudo-constipation.  Here  the  baby  is 
perfectly  happy,  contented,  and  thriving.  Bowel  movements 
occur  perhaps  once  in  two  days.  They  are  normal,  soft,  and 
homogeneous.  The  mother  complains  to  you  bitterly.  She 
has  read  in  her  guide  book,  or  has  been  instructed  by  the  family 
physician,  that  unless  the  bowels  move  once  a  day  the  baby 
won't  sleep,  will  be  restless,  will  have  colic.  As  a  matter  of 
fact,  gentlemen,  these  symptoms  exist  only  in  the  mother's 
mind.  They  are  in  the  guide  book,  or  in  the  advice  obtained 
from  outside  sources,  but  in  the  baby  they  rarely  exist.  He  goes 
sailing  along  perfectly  independent  of  the  anxiety  he  is  causing. 
Has  it  ever  occurred  to  you  to  question  the  authority  which 
states  that  a  baby  must  have  one  bowel  movement  a  day? 
Frequently  I  have  asked  myself,  "By  what  right  has  this  author 
to  state  definitely  that  a  child  must  have  a  bowel  movement 
daily."     We  do  not  lay  down  definite  rules  as  to  the  frequency  of 


DISTURBANCES   IN   THE    BREAST   FED  283 

urination.  We  know  that  this  depends  upon  many  different 
factors. 

The  text-books  make  the  statement,  but  where  is  their  author- 
ity? It  comes,  I  presume,  from  books  written  in  previous  times. 
These  books,  when  written,  were  founded  upon  more  previous 
observations;  and  ultimately,  I  presume,  we  should  find  the 
statement,  like  so  many  we  read,  to  have  originated  in  those 
medieval,  mysterious  ages  when  knowledge  was  dogma  and 
wisdom  superstition.  In  such  cases  I  tell  the  mother,  "For  this 
baby  this  condition  is  normal;  don't  worry.  The  intestine  is 
so  strong  that  he  is  absorbing  almost  all  his  food.  Very  Uttle 
remains  in  the  bowel,  and  two  days  are  required  for  residue  to 
accumulate  sufficiently  to  cause  a  normal  bowel  movement." 
As  I  say,  gentlemen,  this  idea  may  be  wrong,  but  it  gives  good 
practical  results. 

(2)  True  constipation  requires  more  definite  treatment.  Here 
the  stools  are  hard  and  soapy;  i.  e.,  truly  constipated.  They 
do  not  adhere  to  the  diaper,  and  the  baby  may  strain  and  have 
pain.  No  matter  how  well  the  child  may  thrive,  if  he  strains, 
woe  be  to  you  if  you  tell  the  mother  to  let  him  alone!  If  you 
wish  to  retain  your  practice,  you  must  suggest  definite  therapy. 
How  shall  we  proceed?  First,  make  a  careful  examination  to 
rule  out  any  organic  cause,  such  as  tumor  or  a  congenitally  di- 
lated colon.  Shall  we  give  physics?  This  is  not  reasonable. 
Physics  simply  flush  out  the  bowel  but  do  not  correct  the  funda- 
mental cause.  Enemas  often  do  more  harm  than  good.  When 
these  are  repeated  daily,  the  child's  rectum  becomes  sore  and  he 
voluntarily  restrains  himself  to  prevent  the  pain.  Thus  we  de- 
feat our  own  purpose.  If  the  mother  insists  upon  active  treat- 
ment, an  enema  of  one  ounce  or  more  of  olive  oil  may  be  intro- 
duced into  the  rectum  once  or  twice  a  week,  just  before  the  baby 
goes  to  sleep.  Instruct  the  mother  to  hold  the  buttocks  to- 
gether, so  that  the  oil  remains  in  the  intestine  all  night,  and  in 
the  morning,  either  spontaneously  or  from  a  mild  suppository, 
the  child  will  have  a  soft  bowel  movement. 

As  regards  correcting  the  underlying  cause,  we  must  attempt, 
as  closely  as  possible,  to  simulate  the  normal.  In  the  intestine 
of  the  normal  breast-fed  child  a  state  of  mild  fermentation  exists. 
As  you  remember  from  the  lectures  on  artificial  feeding,  such  a 


284  INFANT   FEEDING    (CHICAGO   METHODS) 

condition  may  easily  be  produced  by  the  use  of  fermentable 
carbohydrate.  Offer  your  patient,  after  each  nursing,  an  ounce 
or  more  of  cereal  water  with  5  percent  to  10  percent  lactose,  or 
else  add  from  one-half  ounce  to  an  ounce  after  each  nursing  of  a 
10  percent  watery  solution  of  malt  soup  extract.  In  addition, 
use  fruit-juices,  and  after  the  third  or  the  fourth  month  a  little 
apple-sauce.  With  such  simple  procedure,  these  cases  respond 
readily. 

So  much  for  isolated  symptoms  where  the  babe  as  a  whole  has 
been  unaffected. 

Now  for  those  which  affect  the  weight  curve. 


INANITION 

The  first  of  these,  as  in  the  artificially  fed,  we  might  call 
"failure  to  gain."  In  the  normal  breast  fed  failure  to  gain 
almost  invariably  is  due  to  insufficient  milk,  and  so  usually  is 
inanition.  As  regards  gastro-intestinal  symptoms,  the  stools 
are  of  the  truly  constipated  type,  being  infrequent  and  hard; 
but,  gentlemen,  let  me  urge  that  in  some  cases  stools  are  green, 
watery,  and  contain  mucus  and  curds.  No  worse  mistake  can  be 
made  than  diagnosing  such  cases,  as  so  frequently  is  done,  gas- 
troenteritis from  overfeeding. 

Symptoms  of  general  involvement  are  cessation  of  the  normal 
gain  in  weight,  pallid,  inelastic  skin,  lost  agility,  and  sunken 
abdomen.  The  nervous  system  is  affected.  The  child  may  cry 
continuously,  showing  neurotic  tendencies  by  scratching  the 
skin  of  the  face  and  body.  Crying,  however,  may  be  entirely 
absent. 

Dr.  Woodson  asks:  What  difference  do  you  draw  between 
inanition  and  decomposition? 

Answer. — That  is  rather  a  fine  point,  but  perhaps  rather  a 
practical  one,  too. 

Inanition  is  a  condition  arising  from  insufficient  food.  When 
a  child  is  in  a  state  of  inanition,  increase  his  diet  and  he  will 
gain.  When,  however,  the  inanition  has  proceeded  to  an  ex- 
treme degree,  then  we  speak  of  decomposition.  Now  if  we  add 
food  to  the  diet,  a  paradoxical  reaction  will  result  and  the  weight 
curve  goes  down. 


DISTURBANCES    IN    THE    BREAST   FED  285 

By  simple  inspection  we  scarcely  can  say  whether  the  child 
is  in  a  state  of  simple  inanition  or  whether  this  has  proceeded  to 
a  mild  decomposition.     We  can  tell  only  by  the  reaction  to  food. 

As  a  matter  of  experience,  however,  children  on  the  breast, 
although  they  may  suffer  considerable  inanition,  rarely  proceed 
to  decomposition  as  do  bottle  babies.  It  is  on  the  basis  of  this 
experience,  knowing  that  the  breast  baby,  perhaps  due  to  the 
better  condition  of  his  tissues,  never  proceeds  to  such  a  severe 
stage  as  does  the  bottle  baby,  that  I  am  not  so  careful  with 
their  bottles  in  supplementary  feedings. 

In  the  etiology  of  inanition  several  factors  are  to  be  con- 
sidered : 

(1)  Insufficient  milk  may  be  due  to  failure  of  the  supply  of 
the  mother;  to  retracted  nipples;  or  to  fissured  nipples. 

(2)  The  child  may  be  unable  to  obtain  sufficient  milk,  due  to 
cleft-palate  or  harelip.  What  so  frequently  is  overlooked  is 
weakness  in  the  child.  Small  twins  or  prematures  may  be 
unable  to  obtain  sufficient  nourishment  simply  from  lack  of 
strength. 

(3)  A  so-called  neuropathic  constitution  may  be  the  basis  of 
the  trouble,  resulting  in  a  distracted  physician  and  a  perturbed 
household.  The  mother's  breast  may  be  abundantly  supplied; 
the  shghtest  pressure  may  cause  milk  to  gush  forth.  The  child, 
however,  when  put  to  the  breast,  takes  one  or  two  swallows, 
then  seems  to  show  an  absolute  lack  of  interest  in  anything  con- 
nected with  his  food,  and  lies  disinterestedly  playing  with  the 
nipple.  How  deceptive  is  this  contentment!  Were  we  guided 
in  our  feeding  solely  by  the  baby's  disposition  we  would  com- 
pletely overlook  the  warning  given  by  the  stationary  weight 
curve. 

In  the  newborn  this  neuropathy  manifests  itself  by  some 
difficulty  in  swallowing.  The  nervous  system  is  incompletely 
developed,  and  the  child's  swallowing  reflexes  are  not  as  they 
should  be.  The  child  makes  clumsy,  awkward  attempts.  Dur- 
ing the  third  or  fourth  month,  however,  this  constitution  shows 
itself  in  more  persistent  form;  that  is,  in  a  prolonged  loss  of 
appetite.  Do  what  you  will,  the  little  fellow  takes  no  interest 
in  his  food.  He  smiles  and  is  happy,  but  will  not  nurse.  In- 
variably the  distracted  mother  insists,  "My  milk  is  no  good; 


286  INFANT   FEEDING    (CHICAGO   METHODS) 

the  baby  absolutely  refuses  it."  The  unfortunate  innocent 
physician  gets  a  wet-nurse.  Added  to  his  worries  now  are  not 
only  the  complaints  of  the  mother,  but  also  the  domestic  in- 
felicity arising  from  the  new  acquisition  to  the  family.  The 
baby  refuses  the  breast  of  the  first  wet-nurse  and  she  is  dis- 
charged. Sometimes  four  or  five  are  employed  before  the  un- 
happy, by  this  time  well-nigh  insane,  physician  realizes  that 
fundamentally  the  fault  did  not  lie  with  the  breast  milk,  but  did 
lie  with  the  hahy. 

4.  The  failure  of  the  child  to  gain  may  in  another  way  be  due 
to  insufficient  breast  milk.  He  may  obtain  enough,  but  lose  it 
again  by  vomiting.  As  a  general  rule,  mild  vomiting  does  not 
produce  any  marked  inanition.  The  vomiting  of  the  neuro- 
pathic child  may  be  severe,  however.  It  is  usually  associated 
with  a  spasm  of  the  pylorus  and  is  spastic  in  nature.  A  mother 
in  one  of  our  poorer  districts  described  it  best  to  me  by  saying, 
"John  vomits  the  way  his  pa  spits  tobacco,"  In  this  and  in 
true  stenosis  of  the  pylorus,  disturbance  is  grave  and  severe. 

5.  Lastly,  and  not  to  be  classified  as  inanition,  failure  to  gain 
may  be  a  temporary  affair,  resulting  from  an  acute  dyspepsia. 

Diagnosis. — First,  is  this  a  case  of  inanition,  or  if  the  stools  be 
dyspeptic,  is  it  a  case  of  overfeeding?  Instead  of  wasting  time 
speculating,  simply  weigh  the  baby  for  a  twenty-four-hour 
period  before  and  after  each  nursing,  and  estimate  the  day's 
total  intake.  This  simple  procedure  rather  than  stool  exami- 
nation makes  a  definite  diagnosis. 

Equally  important  is  it  to  diagnose  the  cause.  Retracted  or 
fissured  nipples  speak  for  themselves.  If  the  fault  be  an  in- 
sufficient supply,  the  baby,  after  five  or  ten  minutes,  ceases 
nursing  and  cries  irritably.  Examination  of  the  breast  shows 
it  to  be  empty,  or  if  the  nursing  be  interrupted,  one  finds  that 
the  milk  oozes  from  the  nipple  simply  drop  by  drop. 

If  the  fault  lies  with  the  child,  observation  of  the  nursing 
process  makes  the  diagnoses.  The  clumsy  swallowing  of  the 
newborn  points  to  undeveloped  reflexes.  The  lack  of  interest 
in  the  older  child  shows  the  neuropathic  loss  of  appetite. 

Vomiting  is  recognized  by  the  history  and  the  examination. 

Prognosis.— In  the  breast-fed  this  is  relatively  good.  Rarely 
does  the  breast-fed  child  progress  to  the  stage  of  decomposition 


DISTURBANCES    IN    THE    BEEAST   FED  287 

SO  easily  reached  by  the  bottle  baby.  Decomposition  results 
only  in  extreme  cases. 

Treatment. — Treatment  depends  upon  the  cause.  (1)  If  the 
fault  lies  with  insufficient  milk,  the  child  may  be  put  to  the 
breast  more  frequently  or  else  both  breasts  may  be  used.  If  the 
weight  curve  does  not  rise  after  a  few  days  of  this  treatment,  a 
bottle  may  be  added  after  each  nursing,  the  amount  depending 
upon  the  amount  of  milk  obtained  from  the  breast.  As  children 
wean  themselves  rapidlj^  never  give  the  child  the  bottle  until 
the  breast  has  been  thoroughly  emptied. 

(2)  When  the  fault  lies  with  the  child: 

(a)  If  it  be  due  to  the  undeveloped  reflexes  of  the  newborn, 
we  must  be  patient  for  a  few  weeks.  However,  during  this 
time  don't  allow  the  baby's  nutrition  to  suffer;  and  insist  that 
the  breast  be  emptied  after  each  nursing,  so  that  the  supply  does 
not  fail. 

(6)  If  the  fault  lies  with  loss  of  appetite,  correction  is  more 
difficult.  Sometimes  a  few  drops  of  pepsin  with  dilute  hy- 
drochloric acid,  given  before  each  meal,  stimulate  the  appetite. 
A  daily  stomach  washing  may  be  of  value.  A  lukewarm  bath, 
followed  by  a  cool  spray,  occasionally  gives  striking  results. 
In  the  latter  be  careful  not  to  shock  the  child.  Babies  are  very 
susceptible  to  cold.  Make  the  spray  just  cool  enough  to  be 
mildly  stimulating  and  to  make  the  child  breathe  deeply;  to 
make  him  cry  perhaps,  but  under  no  circumstances  to  shock 
him  severely.  If  this  is  done  once  or  twice  a  day,  a  few  minutes 
before  meal-times,  often  the  child  nurses  with  considerably  more 
vigor. 

During  this  period  of  treatment  the  child's  nutrition  must  by 
no  means  be  neglected.  Here  great  errors  are  made.  The 
physician  too  frequently  says,  ''If  this  child  won't  nurse,  we'll 
let  him  get  so  hungry  that  he  will  have  to."  Such  treatment 
accomphshes  nothing.  The  child's  loss  of  appetite  is  not  due 
to  his  having  obtained  sufficient  food.  It  is  due  to  the  con- 
dition of  his  nervous  system.  Whether  you  give  food  more 
frequently  or  less  frequently,  his  appetite  will  not  change  unless 
the  underlying  fault  can  be  corrected.  Under  these  circum- 
stances, as  the  baby  takes  only  the  slightest  amount  of  food  at 
each  nursing,  put  him  to  the  breast  oftener,  and  then,  if  his 


288  INFANT   FEEDING    (CHICAGO   METHODS) 

weight  curve  doesn't  ascend,  use  forced  feeding,  because  there 
is  no  reason  for  his  nutrition's  suffering  during  the  period  that 
you  are  trying  to  overcome  his  nervous  tendencies.  The  use  of 
a  stomach-tube  may  accompUsh  a  marvelous  cure.  Lastly, 
as  this  neuropathy  is  inherited  from  nervous  parents,  as  the 
baby  makes  the  mother  nervous,  and  the  mother  in  turn  makes 
the  baby  nervous,  at  times  the  only  thing  we  can  do  is  to  order  a 
change  of  environment.  If  you  can  get  a  good  wet-nurse,  a 
sane  woman  who  takes  a  perfectly  disinterested  sort  of  interest 
in  the  child,  results  are  very  gratifying. 

(3)  In  all  cases,  no  matter  what  be  the  cause  of  the  inanition, 
don't  neglect  the  child's  water  supply.  '  Children  suffer  griev- 
ously from  lack  of  water.  In  getting  small  quantities  of  breast 
milk  naturally  they  reduce  markedly  their  water  intake.  In 
your  treatment  don't  neglect  to  make  up  this  deficiency. 

The  other  marked  disturbance  is  dyspepsia,  which  is  much 
like  that  arising  on  the  bottle. 


DYSPEPSIA 

Gastro-intestinal  symptoms  are  vomiting,  regurgitation,  diar- 
rhea, anorexia,  flatulence,  tympanites,  and  colic. 

General  symptoms  other  than  gastro-intestinal  are  cessation 
of  gain,  change  in  the  quahty  of  the  skin,  slight  fever,  nervous 
reactions,  as  sleeplessness  and  unrest,  and  decreased  immunity 
to  infection. 
Etiology. — Several  factors  may  be  concerned : 
(1)  Alimentary  influences  up  to  the  present  have  been  con- 
sidered most  important. 
Alimentary   Influences. — (a)    Overfeeding  is   given   the 
first  place.     Gentlemen,  I  don't  want  to  be  too  radi- 
cal, but  I  believe  that  more  and  more  we  are  beginning 
to  doubt  the  importance  of  overfeeding.     As  the  im- 
portance of  constitution  grows  in  our  mind,  as  we  recog- 
nize the  neuropathic  type  of  child  and  other  types, 
too,  as  we  recognize  fundamental  differences  in  the 
baby  himself,  just  so  much  are  we  decreasing  our 
emphasis  on  the  outside  factors.     Irregularity  of  feed- 


DISTURBANCES   IN   THE    BREAST   FED  289 

ing  in  our  mind  is  perhaps  much  more  important 
than  is  overfeeding,  and  let  me  remind  you  that  ir- 
regularity of  feeding  is  due  frequently  to  underfeeding 
rather  than  to  overfeeding.  Indeed,  we  are  beginning 
to  doubt  whether  many  cases  do  result  from  over- 
feeding. So  great  is  the  adaptability  of  the  mother's 
breast  to  the  baby's  demands, — when  the  baby  wants 
more,  more  milk  is  secreted;  when  the  baby  wants 
less,  less  is  secreted, — so  great  is  this  adaptability  that 
if  the  child  be  nursed  regularly  every  four  hours  it  is 
a  question  whether  many  mothers  can  overfeed  their 
babies.  Perhaps  overfeeding  is  a  factor  when  an 
undernourished  infant  is  put  to  the  breast  of  a  fine, 
healthy  wet-nurse.  Before  the  baby  has  adapted  it- 
self to  the  breast,  and  vice  versa,  often  too  much  milk 
is  taken. 

Such  statements  are,  of  course,  heresy,  gentlemen,  but 
weigh  the  baby  before  and  after  nursing  and  see  for 
yourselves. 

(&)  Of  alimentary  factors,  we  believe  irregularity  of 
nursing  to  be  most  important,  but  don't  forget  inani- 
tion may  produce  a  picture  identical  to  dyspepsia. 

(c)  Foreign  substances  secreted  in  breast  milk  and 
causing  this  dyspepsia  we  believe  very  rare  indeed. 

id)  Shifting  proportions  of  the  different  elements,  as, 
for  example,  too  much  fat,  are  described.  Undoubt- 
edly some  breast  milk  contains  more  fat  than  the 
average.  As  the  stools  of  many  of  these  children, 
however,  are  typically  fermentative,  frequently  do  I 
wonder  whether  perhaps  too  much  sugar  is  not  being 
secreted.  In  all  cases  very  little  scientific  evidence 
proves  that  disturbances  arise  from  these  sources.  We 
may  learn  more  later.  As  I  mentioned  in  our  last 
lecture,  one  will  make  fewest  grave  errors  if,  for  the 
present,  he  considers  that  invariably  breast  milk  is 
perfect  in  quality  and  disturbances  are  due  only  to 
changes  in  quantity. 
(2)  Infections. — The  more  dyspepsias  we  see  on  the  breast, 

the  more  do  we  reahze  the  fundamental  influence  of  in- 
19 


290  INFANT   FEEDING    (CHICAGO   METHODS) 

fection.  A  baby  has  been  thriving,  becomes  infected 
with  a  nasopharyngitis,  a  bronchitis,  an  otitis,  or  a 
cystitis,  and  a  dyspepsia  results.  When  the  infection 
has  run  its  course,  the  intestinal  tract  corrects  itself, 
fermentation  ceases,  and  the  stools  become  normal. 
In  this  type,  frequent  errors  are  made.  The  mother 
says  the  milk  is  not  agreeing  with  the  baby.  The 
physician  may  prescribe  a  wet-nurse;  may  take  the 
baby  from  the  breast;  may  order  medicine  for  the 
child;  may  diet  the  mother;  and  in  spite  of  all  treat- 
ment, improvement  occurs.  Why?  Improvement 
does  not  result  from  the  therapy;  it  occurs  because 
the  child  has  recovered  from  the  infection.  In  all 
cases  of  dyspepsia  on  the  breast  don't  neglect  search- 
ing for  parenteral  infections. 
(3)    Our  old  enemies,  overclothing,  overheating,  improper  care, 

overcooling,  are,  of  course,  never  to  be  overlooked. 
The  sjmiptoms  depend  to  some  extent  upon  the  cause.  Those 
due  to  alimentary  factors  develop  gradually.  Nerv^ous  changes, 
with  disturbed  sleep  and  restlessness,  manifest  themselves  first. 
Later  symptoms  of  the  gastro-intestinal  tract  develop.  General 
symptoms  and  fever  are,  as  a  rule,  not  severe.  The  type  due  to 
infection  appears  rather  suddenly  in  the  previously  thriving 
child.  General  symptoms  and  fever  are  more  in  evidence  than 
in  the  former. 

The  severity  of  the  reaction  and  the  course  depend  upon  the 
child's  constitution — the  better  the  constitution,  the  less  the 
reaction.  The  aUmentary  tj^pe  is  progressive  and  often  ends  in 
anorexia.  The  infectious  type  is  short  and  ends  in  a  cure,  with 
recovery  from  the  infection. 
Diagnosis. — The  diagnosis  is  made  from  the  history. 
Treatment. — The  treatment  is  relatively  easy  where  ali- 
mentary factors  can  be  corrected.  Where  infection  is  the  basis 
of  the  disturbance,  wait.  In  all  cases,  and  in  that  mentioned 
at  the  beginning  of  the  lecture,  powdered  casein  is  of  value. 
Formerly  this  could  be  obtained  as  a  powder.  Since  the  war  I 
doubt  if  it  is  obtainable,  but  we  may  make  it  by  getting  the 
curds  of  milk  and  putting  them  through  a  sieve.  You  remember 
that  casein  makes  the  intestine  alkaline,  and  as  most  of  these 


DISTURBANCES   IN   THE   BREAST  FED  291 

diarrheas  are  of  a  fermentative  nature,  casein  is  ideally  suited  to 
our  requirements.  Give  it  in  doses  of  one  or  two  teaspoonfuls 
after  each  nursing,  and  increase  until  you  obtain  the  desired 
results.  Albumin  milk  may  work  wonders  in  small  doses  after 
nursing. 

One  must  never  neglect  the  general  care  of  the  child,  and  in- 
quire earnestly  into  the  conditions  in  the  household,  clothing, 
and  general  hygiene. 

One  danger  leads  to  serious  complications.  The  mother  or  the 
physician,  not  recognizing  that  an  infection  is  the  cause,  lays 
great  emphasis  upon  the  importance  of  the  breast  milk.  Some- 
thing must  have  affected  its  quality.  Therefore  we  take  the 
baby  from  the  breast  and  starve  him  until  the  milk  has  corrected 
itself  and  until  the  stools  become  normal.  Gentlemen,  all 
that  we  have  accomphshed  is  to  add  to  our  patient's  troubles 
the  damaging  influence  of  hunger.  Frequently  he  gets  better 
with  this  treatment,  but  this  change  is  due  to  cessation  of  the 
infection.  Don't  make  unnecessary  use  of  hunger.  Children 
have  so  much  intelhgence, — often  so  much  more  than  we, — if 
you  weigh  the  baby  before  and  after  nursing  you  will  find  that 
instinctively  he  cuts  down  his  diet.  You  will  find  that  he 
drinks  far  less  during  these  few  days  than  ordinarily.  It  is  my 
custom  simply  to  put  the  child  to  the  breast,  allow  him  an  in- 
terval shorter  than  usual, — five  minutes,  for  example, — and  to 
repeat  this  at  the  regular  feeding  time,  but  never  let  him  hunger 
markedly.  By  this  procedure  you  will  find  that  during  these 
few  trying  days  the  baby's  general  nutrition  is  maintained. 

From  the  above  you  see  how  unnecessary  in  many  cases  is  a 
wet-nurse.  The  fault  lies  so  frequently  with  the  baby,  rather 
than  with  the  milk,  so  frequently  with  outside  factors,  such  as 
infections,  rather  than  with  the  mother  herself. 

Just  one  word  about  severe  diarrheas  occurring  in  the  breast 
fed.  Breast-fed  children,  rarely  it  is  true,  but  still  definitely, 
do  develop  symptoms  almost  identical  to  the  alimentary  in- 
toxication of  the  bottle  baby.  Our  previous  ideas  were  that  a 
toxin  was  secreted  by  the  breast  milk.  I  believe  this  has  been 
disproved.  I  doubt  if  people  ever  find  human  breast  milk 
definitely  poisonous  to  the  child.  However,  we  are  learning  to 
recognize  other  factors.     We  are  learning  that  parenteral  in- 


292  INFANT   FEEDING    (CHICAGO   METHODS) 

fections;  true  intestinal  infections,  such  as  dysentery;  or  over- 
heating may  be  the  basis  of  the  trouble,  and,  lastly,  we  have 
learned  that  children  in  states  of  severe  decomposition,  when 
given  large  quantities  of  any  breast  milk  whatsoever,  go  down 
and  die  with  the  severest  alimentary  symptoms. 

The  treatment  is  identical  to  that  of  the  aUmentary  intoxica- 
tion or  true  infections  of  the  artificially  fed. 

This  finishes,  gentlemen,  infant  feeding.  There  are  many, 
many  more  phases  of  this  interesting  subject  which  I  should 
like  to  discuss  with  you.  Time,  however,  forbids.  If  you  have 
followed  me  carefully  you  will  perhaps  have  obtained  some  idea 
of  the  methods  of  our  Middle  West,  as  I  understand  them. 
I  do  not  urge  these  exclusively  upon  you.  I  trust  that  you  have 
become  interested  and  will  investigate  the  teachings  of  the  great 
men  all  over  this  country  of  ours.  After  you  have  obtained  a 
comprehensive  view  of  the  whole  field,  select  the  method  which 
pleases  you  most,  or,  better  yet,  you  may  be  in  a  position  to 
select  from  the  different  teachings  many  points  of  value,  and  I 
trust  that  you  will  use  them  all,  no  matter  what  their  source,  to 
aid  sick  and  suffering  children. 


CLINICS 

CLINIC  I 

Gentlemen,  I  asked  you  to  bring  normal  babies  to  the  clinic 
today  for  two  reasons:  First,  no  satisfactory  work  in  infant 
feeding  can  be  accomplished  without  a  thorough  understanding 
of  the  normal  infant,  who  represents  the  ideal  for  which  we  are 
striving.  Second,  you  have  learned  that  from  the  viewpoint 
of  infant  feeding  it  is  wiser  to  consider  the  artificially  fed  baby 
as  a  sick  baby.  For  this  reason,  no  matter  how  well  he  may 
seem,  before  you  prescribe  feedings  you  must  obtain  an  accurate 
history  and  a  careful  physical  examination. 

(Normal  children  are  brought  by  Dr.  J.  W.  Long  (Greens- 
boro), Dr.  F.  Raymond  Taylor  (High  Point),  and  Miss  Powers 
(Winston-Salem) . 

Dr.  Long's  patient  demonstrated. 

Gentlemen,  just  step  up  and  feel  the  texture  of  this  skin. 
Put  your  hand  on  it  and  notice  its  dehcacy,  its  velvety  softness. 
The  first  touch,  more  than  the  first  glance,  diagnoses  the  breast- 
fed baby.  Notice  the  fineness,  the  elasticitj%  and  the  fullness. 
Note  the  smoothness,  the  splendid  state  of  nutrition,  the  delicate 
pink  color.  Feel  the  subcutaneous  tissue.  Strange  that  the 
first  thing  we  see  in  looking  at  any  patient  is  the  skin,  and  yet 
in  our  examination  it's  the  most  neglected  of  all  organs.  In 
future  clinics  we  shall  learn  what  marked  changes  in  elasticity, 
fullness,  softness,  and  color  it  undergoes  during  the  development 
of  disturbances  of  nutrition.  Indeed,  with  eyes  blindfolded — 
practically  by  palpation — ^we  can  diagnose  such  disturbances. 

In  this  normal  baby  notice  the  well-developed  muscles — their 
normal  tone,  neither  too  rigid  nor  too  flaccid.  Note  the  abdo- 
men, not  retracted,  not  bulging,  just  about  the  level  of  the 
thorax.  We  haven't  this  baby's  weight,  but  he  looks  approxi- 
mately 16  to  18  pounds,  which  would  be  normal  for  a  baby  of 
about  six  months. 

Above  all  things,  notice  his  contentment,  his  happy  smile, 

293 


294 


INFANT  FEEDING    (CHICAGO   METHODS) 


his  fearlessness.    Note  how  he  reaches  for  my  watch  and  wants 
to  play  (Figs.  32  and  33). 


Fig.  32. 


Fig.  33. 


Fig.  34. 


CLINICS  295 

Note  how  joyfully  he  stamps  and  kicks  and  waves  his  arms. 
I  clap  my  hands;  he  looks  at  me  with  a  somewhat  inquisitive, 
rather  pained  expression;  he's  disappointed  in  me;  but  he's 
normal  (Fig.  34).  He  doesn't  shriek  with  terror  as  would  a  baby 
with  a  neuropathic  constitution. 

Having  satisfied  ourselves  as  to  the  state  of  his  nutrition,  we 
ask,  "Has  he  developed  normally?" 

I  see  by  Dr.  Long's  expression  that  he  thinks  we  have  abused 
his  protege  sufficiently;  so  let's  persecute  this  one  of  Dr.  Tay- 
lor's. I  wish  you  gentlemen  would  come  up  and  examine  him, 
and  then  go  to  your  seats  and  write  on  a  slip  of  paper  your  esti- 
mate of  his  age. 

Well,  for  such  a  superficial  examination,  you  have  done  better 
than  you  deserve. 

In  estimating  a  child's  age,  you  must  take  into  consideration 
many  points.     We  reason  as  follows :  First,  is  he  a  newborn? 

No.  The  skin  has  not  the  characteristic  bright-red  color  of 
an  Apache  Indian;  it  is  not  covered  with  vernix  caseosa,  and 
baby's  size,  of  course,  contradicts  such  an  assumption.  Again, 
the  skin  of  the  newborn  desquamates  for  about  ten  days.  This 
skin  shows  no  trace  of  desquamation.  The  breasts  in  all  normal 
children  secrete  during  the  first  week,  sometimes  a  few  days 
longer.  When  these  breasts  are  compressed,  no  trace  of  fluid 
exudes.  Again,  in  normal  babies  the  cord  falls  ofif  within  four 
days.  In  this  child  not  only  has  the  cord  disappeared,  but  the 
navel  has  also  healed  perfectly.  This  shows  him  to  be  over 
three  weeks. 

Has  he  reached  the  normal  development  of  a  child  of  two  to 
three  months? 

Question. — Mother,  does  he  recognize  you?  Does  he  smile 
when  he  sees  you?  We  don't  need  an  answer.  That  smile 
speaks  for  itself. 

Question. — Does  he  notice  things?  We'll  try  him.  See  how 
the  eyes  follow  my  flashlight!  See  the  interest  he  takes!  He 
follows  not  only  with  the  eyes,  but  with  the  whole  head.  All 
this  confirms  our  opinion  that  he  is  at  least  two  to  three  months 
of  age.  Interesting,  is  it  not,  that  when  a  baby  first  starts  to 
notice  external  affairs  he  follows  with  only  one  eye,  and  so  dur- 
ing the  first  four  to  eight  weeks  strabismus  is  normal?    By  the 


296 


INFANT  FEEDING    (CHICAGO  METHODS) 


end  of  the  second  month,  however,  he  follows  with  both,  and 
with  the  head  too.  So  this  baby  easily  has  passed  eight  weeks 
(Figs.  35  and  36). 


Fig.  35. 


/ 


Fig.  36 


CLINICS  ■  297 

Is  he  over  three  months  of  age? 

Does  he  hold  up  his  head? 

He  does  this  very  well,  either  when  raised  by  the  shoulders 
from  the  table  or  when  lying  on  his  stomach.  So  he  is  three 
months  or  more.  At  three  months  tears  appear  for  the  first 
time,  as  does  drooling,  and  coordinate  movements  of  the  ejt- 
tremities  show  a  beginning  of  voluntary  muscular  control. 

Question. — Mother,  does  he  recognize  famiUar  noises? 

Answer. — Yes,  he  knows  my  voice  and  also  his  father's. 

That  shows  he  must  be  four  months  or  more. 

Does  he  sit  up  yet?  Well,  he's  making  a  brave  attempt, 
but  I  guess  it's  too  heroic  a  task.  And  he  has  no  teeth  either. 
At  six  months  a  baby  begins  to  sit  up,  shows  two  lower  central 
incisors,  and  has  doubled  his  birth  weight.  From  this. child's 
size  he  must  be  almost  six  months.  But  he  doesn't  sit  up,  and 
so  I  judge  him  to  be  perhaps  five  months,  or  a  little  more. 

Question. — Is  that  right,  mother? 

Answer. — (Proudly.)     He  is  four  months  and  three  weeks. 

Well,  here  we  have  not  only  a  baby  normal  in  every  respect, 
but  also  one  who  is  a  little  ahead  of  time;  so,  mother,  you  may 
be  proud  of  him. 

It  will  be  very  interesting  to  watch  the  development  of  this 
young  man.  When  he  reaches  the  dignified  age  of  nine  months, 
if  supported,  he  will  attempt  to  stand,  and  his  vocabulary  will 
include  such  choice  words  as  "pa,"  "ma,"  and  "goo."  Nine 
to  twelve  months  may  find  him  attempting  to  walk.  At  the 
end  of  the  first  year  he  will  treble  his  birth  weight  and  will  have 
six  to  eight  teeth.  The  large  anterior  fontanel  will  close  be- 
tween twelve  and  eighteen  months.  The  posterior,  as  you  know, 
is  closed  at  or  shortly  after  birth. 

You  may  wonder  what  all  this  has  to  do  with  infant  feeding. 
Simply  this:  If  the  baby  is  not  normal  as  regards  his  physical 
and  mental  development,  you  must  make  allowance  in  your 
formulas.  If  you  limit  yourselves  to  rules  and  regulations  which 
concern  themselves  only  with  baby's  age  or  his  weight,  you  will 
meet  with  unavoidable  failure.  Baby's  tolerance  to  food  is  the 
vital  factor,  and  this  you  estimate  by  careful  history  and  by  con- 
scientious physical  examination.  As  a  rule,  the  more  deficient 
the  child's  physical  development,  the  less  will  be  his  tolerance. 


298  INFANT   FEEDING    (CHICAGO   METHODS) 

If  we  do  our  work  thoroughly,  we  should  examine  every  nor- 
mal baby  as  carefully  as  we  do  a  sick  one.  Time  prevents  this 
morning,  but,  nevertheless,  I  am  going  to  take  just  a  moment  to 
examine  the  heart.  I  advise  you  in  all  cases,  in  addition  to 
general  inspection,  no  matter  how  healthy  or  normally  devel- 
oped the  child  may  seem,  never  to  neglect  this.  You  will  find 
congenital  heart  lesions  not  uncommon,  and  from  my  own  ex- 
perience I  beheve  more  and  more  that  these  lesions  are  impor- 
tant factors  in  influencing  the  baby's  nutrition  and  predisposing 
him  to  disturbances. 

I  think  we  have  abused  this  child's  good  nature  sufficiently. 

Let's  see  the  next. 

CLnnC  L— BABY  1 
Brought  by  Dr.  W.  T.  Meadows  (Greensboro) 

Question. — Doctor,  is  this  baby  to  be  demonstrated  as  a  well 
baby  or  as  a  sick  one? 

Answer. — He  has  been  breast  fed  until  the  present,  and  up  to 
three  weeks  ago  had  been  doing  nicely.  Since  then  he's  not 
been  thriving.  I  saw  him  for  the  first  time  yesterday,  and  sug- 
gested that  the  mother  bring  him  to  the  cHnic. 

Discussion. — Good!  Here  then  we  can  demonstrate  the 
methods  of  history  taking.  I'll  go  over  this  one  in  detail  to 
show  the  procedure.  After  this  I'm  going  to  ask  you  gentlemen 
to  take  these  histories  in  advance,  so  as  to  save  time.  Before 
starting,  however,  let  me  impress  upon  you  that  in  all  our  work 
we  are  going  to  adopt  the  attitude  of  the  pediatrician,  the  chil- 
dren's specialist,  rather  than  that  of  the  general  practitioner. 
We  are  not  simply  going  to  say,  "What's  the  matter  with  this 
baby?"  and  offer  a  little  medication,  but  we  must  use  every 
means  at  our  disposal  to  find  out  with  "just  what  soii"  of  child 
we  are  dealing.  We  cannot  hope  for  success  in  our  feeding 
unless  we  know  something  of  the  general  make-up  of  our  patient, 
and  this  knowledge  we  obtain  first  by  careful  history,  and  sec- 
ond by  conscientious  physical  examination. 

Question. — Doctor,  will  you  please  take  this  card  and  fill  it 
out  as  follows:  On  the  upper  left-hand  corner  write  the  baby's 
name;  on  the  upper  right,  his  age. 


CLINICS  299 

Question. — Mother,  how  old  is  the  baby? 

Answer. — Just  four  months  and  one  week. 

The  first  questions  in  this  history  are  those  concerning  the 
family.  The  influence  of  heredity  must  never  be  overlooked. 
Doctor,  will  you  kindly  write: 

Family  History. — Question. — Mother,  are  you  in  good  health? 

Answer. — Yes;  I  didn't  feel  very  strong  just  before  the  baby 
came,  but  I'm  all  right  now.     I'm  always  pretty  well. 

Question. — Is  the  baby's  father  in  good  health? 

Answer. — Yes,  he's  never  been  very  sick  in  his  life  except  once. 

Question. — What  did  he  have? 

Answer. — Typhoid  fever. 

Question. — Are  there  any  nervous  sicknesses  in  your  family? 
Have  any  relatives — your  father,  mother,  brothers,  or  sisters,  or 
your  husband's  brothers  and  sisters  or  parents — ever  been  in  any 
institution  for  any  nervous  sickness? 

Answer. — No;  there  have  been  no  such  sicknesses  in  the 
family,  or  at  any  rate  none  that  I  know  of. 

Discussion. — The  reason  I  asked  this  is  that  many  children 
are  predisposed  to  nervous  trouble  by  heredity.  It's  hardly 
necessary  to  mention  that  severe  nervous  disease,  or  alcoholism 
in  the  parents,  often  leads  to  epilepsy  or  nervous  degeneracy  in 
the  child,  and  this  latter,  in  its  turn,  frequently  gives  rise  to 
nutritional  disturbance. 

Question. — Have  you  or  your  husband,  or  any  of  your  rela- 
tives, or  any  of  your  husband's  relatives,  ever  had  any  lung 
sickness? 

Answer. — There  has  been  no  severe  lung  sickness  in  our  fam- 
ily. Both  my  husband  and  I  at  times  have  had  severe  coughs, 
but  they  have  been  of  short  duration,  and  the  doctor  said  they 
were  simple  bronchitis. 

Discussion. — We  are  particularly  interested  in  lung  diseases 
because  we  know  tuberculosis  in  the  parent  is  a  frequent  cause 
of  feeble,  poorly  developed  offspring,  and,  secondly,  even  though 
these  children  may  not  be  born  with  tuberculosis,  in  such  an 
environment  they  readily  become  infected.  Of  course,  tubercu- 
losis is  a  great  factor  in  predisposing  to  nutritional  disturbance. 

The  next  points  to  be  considered  in  the  family  history  are  the 


300  INFANT  FEEDING    (CHICAGO   METHODS) 

number  of  children,  the  health  of  these  children,  and  the  num- 
ber of  miscarriages. 

Question. — How  many  children  have  you? 

Answer. — This  is  the  only  one. 

Discussion. — Gentlemen,  look  out.  Keep  your  eyes  open  for 
the  only  child;  he's  always  exceedingly  difficult  to  examine. 
Usually — excuse  me,  mother — he's  just  a  little  bit  spoiled.  He 
hkes  his  own  way,  and  looks  upon  the  doctor  as  a  decided  enemy. 
See!  He's  preparing  for  the  battle.  We  must  handle  him  with 
great  care  and  discretion. 

Question. — Have  you  lost  any  children? 

Answer. — I  lost  two  of  coHtis. 

Question. — How  old  were  they? 

Answer. — One  was  nine  months  and  one  two  years. 

Question. — Have  you  had  any  miscarriages? 

Answer. — None. 

Discussion. — We're  glad  to  know  that,  because  miscarriages 
make  us  at  any  rate  think  of  syphilis.  By  no  means  has  every 
mother  who  suffers  from  miscarriage  syphilis,  but  if  we  should 
get  a  history  of  miscarriages  as  follows:  for  instance,  one,  say, 
at  four  months,  another  one  a  little  later,  say,  at  six  months, 
a  third  one  a  little  later,  for  example,  at  eight  months,  and  then 
perhaps  a  baby  born  dead,  we  are  justified  in  being  very  sus- 
picious of  congenital  syphilis,  and,  as  I  tried  to  emphasize  be- 
fore, in  infant  feeding  we  must  try  to  keep  our  eyes  open  for 
every  influence  that  possibly  can  have  been  exerted  upon  the 
baby. 

This  child  seems  to  have  a  perfect  family  history.  Nothing 
from  this  standpoint  will  influence  our  feeding  orders.  We  next 
ask  if  any  factors  in  his  past  life  are  of  importance. 

Past  History. — Question. — Mother,  were  you  well  before  the 
baby  was  born? 

Answer. — I  suffered  from  headaches  and  backache  and  felt  a 
httle  weak,  but  never  had  any  serious  complaint. 

Question. — No  kidney  trouble  or  convulsions? 

Answer. — No. 

Question. — Is  this  a  full-term  baby,  or  did  he  come  too  soon? 

Answer. — He  was  full-term. 

Discussion. — We  are  interested  in  knowing  this  because  pre- 


CLINICS  301 

matures  are  far  more  susceptible  to  nutritional  disturbances 
than  are  full-term  babies,  and  must  be  handled  with  special 
care.     Of  particular  importance  is  the  next  subject: 

Question. — Was  the  labor  difficult?  Was  there  any  serious 
complication?    Was  it  necessary  to  use  any  instruments? 

Answer. — The  doctor  told  me  my  case  was  normal. 

Question. — Did  the  baby  cry  as  soon  as  he  was  born,  or  did 
the  doctor  have  any  trouble  with  him?  Did  the  doctor  tell  you 
that  he  was  suffocated,  or  blue,  or  that  he  was  almost  like  dead? 

Answer. — No,  he  cried  right  away  and  seemed  all  right.  Dr. 
Brown  said  he  was  a  fine  baby. 

Discussion. — These  are  important  questions.  I  ask  about 
difficult  labor  and  about  instruments  because  these  complica- 
tions may  cause  direct  cranial  injury  with  a  resulting  menin- 
geal hemorrhage,  or  by  producing  a  great  rise  in  blood-pressure 
from  asphjTcia  may  indirectly  cause  the  hemorrhage.  Such 
a  hemorrhage  injures  the  brain.  As  a  result,  the  child  does 
not  develop  properly,  and  although  he  may  show  no  marked 
symptoms  at  first,  by  the  time  he  reaches  five  or  six  months  of 
age  he  presents  a  grave  and  most  distressing  picture.  He  is 
very  backward,  his  mentality  is  deficient,  his  limbs  are  rigid,  and 
often  crossed  like  scissors.  In  the  clinics  which  are  to  come  I 
haven't  the  slightest  doubt  that  we  shall  see  such  cases  of  so- 
called  Little's  disease,  and  you  will  learn  how  this  condition 
affects  the  general  nutrition  of  the  child.  Children  with  mental 
defects  are  very  difficult  to  feed,  and  many  of  them  suffer  ex- 
treme inanition  from  loss  of  appetite. 

Question. — How  much  did  he  weigh  at  birth? 

Answer. — We  had  no  scales  at  home,  but  Dr.  Brown  esti- 
mated him  at  11  pounds. 

Discussion. — He  certainly  was  a  fine  youngster.  Most  babies 
average  about  6  to  8  pounds  at  birth. 

Answer. — All  our  North  CaroHna  babies  are  larger  than  that. 

Question. — What  sicknesses  has  the  baby  had? 

Answer. — He's  had  nothing  but  an  occasional  cold. 

Question. — Has  he  ever  had  measles  or  whooping-cough? 

Answer. — No. 

Question. — Does  he  get  very  sick  with  these  colds? 

Answer. — No.     He  doesn't  get  sick  at  all. 


302  INFANT   FEEDING    (CHICAGO   METHODS) 

Discussion. — In  this  way  we  learn  first  the  diseases  which 
have  influenced  this  child's  life.  We  are  particularly  interested 
in  measles  and  pertussis  because  they  so  often  predispose  to 
tuberculosis.  Secondly,  we  learn  the  nature  of  his  resistance. 
The  better  the  condition  of  nutrition,  as  a  rule,  the  more  perfect 
is  the  resistance. 

Question. — Has  the  child  developed  in  the  right  way? 

Discussion. — This  is  hardly  a  question  that  mother  can 
answer.  We  can  learn  this  more  satisfactorily  in  our  examina- 
tion. Inspection  of  this  apparently  normal  baby  and  the  his- 
tory of  the  well-developed  resistance  to  infection  make  us  think 
that  he  either  has  been  breast  fed  or  has  been  fed  perfectly  on 
the  bottle.     This  brings  us  to  the  subject  of  feeding. 

Feeding  History. — Question. — How  has  the  baby  been  fed? 

Answer. — He  has  been  breast  fed  up  to  the  present. 

Question. — How  often  have  you  been  nursing  him? 

Answer. — I  was  giving  him  the  breast  every  two  or  three 
hours. 

Question. — Was  he  satisfied  with  it?    Was  he  gaining? 

Answer. — He  seemed  going  nicely  until  about  two  or  three 
weeks  ago.  For  the  last  two  weeks,  however,  he  has  been  pee- 
vish and  irritable.  He  hasn't  been  gaining,  and  has  been  very 
constipated.  He  won't  take  the  breast  any  more,  and  I've 
given  him  a  Uttle  sugar  water  between  meals.  He  likes  that 
pretty  well,  but  he  vomits  a  lot. 

Question. — How  often  do  his  bowels  move? 

Answer. — Well,  they  don't  move  every  day  unless  I  give  him 
an  injection. 

Question. — When  they  move,  are  they  hard  or  soft? 

Answer. — They  are  usually  soft. 

Question. — Let's  see  if  this  is  correct.  Here  is  a  baby  who 
was  well  up  to  some  weeks  ago.  Then  he  became  cross,  irri- 
table, constipated,  stopped  gaining,  didn't  nurse  as  well  as 
previously,  and  didn't  seem  contented.     Is  that  right,  mother? 

Answer. — Yes. 

Discussion. — Now,  gentlemen,  following  the  feeding  history, 
we  take  the  present  complaint  to  learn  if  the  child  has  been 
feverish,  has  been  coughing,  sneezing,  or  showing  any  other 
abnormal  symptoms. 


CLINICS  303 

Present  Complaint. — In  this  case  the  feeding  history  probably 
will  be  synonymous  with  the  present  complaint. 

Question.— Does  he  show  any  other  symptoms,  like  fever,  or 
have  you  noticed  anything  else  the  matter  with  him? 

Answer. — No,  that  is  all  we  noticed. 

Physical  Examination. — Question. — Mrs.  Peck,  what  is  the 
baby's  weight? 

Answer. — Eleven  pounds  two  ounces.     Temperature,  98°  F. 

Discussion. — This  would  be  a  good  weight  for  a  baby  who 
weighed  six  or  seven  pounds  at  birth.  But  if  he  weighed  almost 
eleven  pounds  he  certainly  hasn't  gained  very  much. 

Gentlemen,  I'm  going  to  examine  him  very  carefully  to  show 
the  methods.  No  matter  how  convinced  we  are  that  it's  simply 
a  feeding  case,  we  never  should  establish  a  diagnosis  before 
making  a  thorough  examination.  We  must  rule  out  every  other 
possibility  and  arrive  at  feeding  more  by  exclusion  than  in  any 
other  way. 

Always  remember,  before  confining  yourself  to  any  local 
examination,  to  look  at  the  baby  as  a  whole.  Here  we  see  a 
fairly  nourished  infant.  He  doesn't  look  so  very  sick;  he 
doesn't  look  unhappy — you  notice  he  smiles  at  us,  but  the  smile 
is  a  little  feeble.  Notice  this  somewhat  flabby,  inelastic  skin; 
the  color,  too,  isn't  that  of  the  normal  children  we  just  have 
examined;  it  has  the  slight  muddy  tinge  which  we  know  to  be 
an  important  symptom.  I  pick  it  up  and  it  wrinkles  rather 
easily.  It  seems  softer  than  the  skin  of  the  other  children. 
The  subcutaneous  tissue  is  less  firm  and  allows  the  skin  unusual 
motility.  Notice  the  lack  of  tone  of  the  muscles.  They  feel 
flabby.  All  these  findings  are  suggestive  of  a  disturbance  of 
nutrition. 

As  a  routine,  however,  we  examine  every  part  of  the  body. 
The  osseous  system,  you  know,  is  very  important  in  infants. 
We  feel  the  large  fontanel,  which,  of  course,  is  widely  open,  but 
it's  neither  sunken  nor  under  tension.  We  feel  for  softness  in 
the  bones  behind  the  ears — craniotabes.  We  find  none.  We 
feel  for  beading  of  the  ribs  where  they  join  the  sternum — the 
rosary.  This,  too,  is  absent.  Both  of  these  symptoms  are  very 
suggestive  of  rickets.  As  a  routine,  we  examine  all  the  lymph- 
nodes — the  cervical,  the  axillary,  the  cubital,  and  the  inguinal. 


304  INFANT   FEEDING    (CHICAGO    METHODS) 

We  find  nothing  except  a  few  the  size  of  a  pea  in  the  posterior 
portion  of  the  neck.  The  more  children  we  examine,  the  less 
significance  we  lay  upon  a  few  palpable  nodes. 

Next  we  seek  abnormahties  about  the  head.  The  eyes,  ears, 
and  nose  show  nothing.  Everything  is  normal.  You  notice 
we  let  the  mouth  and  throat  go  for  the  present,  because  this  child 
is  so  good  we  don't  want  to  make  him  cry.  It's  a  good  routine 
to  leave  the  mouth  and  throat  examination  for  the  last. 

We  feel  for  rigidity  of  the  neck — it's  absent.  We  carefully 
percuss  the  heart  and  limgs  and  auscultate.  Everything  is  nega- 
tive. We  feel  for  an  enlarged  liver  and  spleen.  The  flaccidity 
of  the  abdominal  muscles  makes  this  easy.  I  don't  feel  the 
spleen.  The  liver  reaches  one  finger  below  the  costal  margin. 
This  is  of  no  significance.  There  are  no  other  abnormalities. 
We  examine  the  reflexes — the  triceps,  knee-jerk,  Achilles,  and 
abdominal  reflexes.  They  are  all  brisk,  equal,  and  show  no 
definite  findings.  So  in  this  case  our  physical  examination  is 
absolutely  negative. 

Gentlemen,  by  no  means  does  this  finish  the  examination. 
In  every  case  where  anything  in  the  family  history  makes  us 
in  any  way  suspect  lues  we  never  must  be  satisfied  until  we  have 
a  Wassermann,  and  that  means  a  Wassermann  on  the  mother 
as  well  as  the  baby.  The  Wassermann  of  the  parent  is  perhaps 
the  more  accurate. 

Again,  where  the  child  in  any  way  has  been  exposed  to  tu- 
berculosis, we  must  demand  a  VOn  Pirquet  test.  Where  anything, 
such  as  extreme  pallor  or  enlarged  spleen,  suggests  blood  dis- 
eases, we  examine  the  blood,  and  the  stool  for  hook-worm,  and, 
of  course,  as  a  matter  of  routine,  where  there  is  the  shghtest 
suggestion  of  trouble,  or  even  the  slightest  possibility,  never 
omit  a  urinalysis.  Cystitis  is  very  common,  but  frequently 
overlooked. 

As  to  methods  of  obtaining  urine.  In  a  boy  it  is  simple. 
Simply  attach  a  bottle  or  rubber  glove  with  adhesive.  In  a 
Uttle  girl  it's  more  difficult.  Sometimes  a  cool  bath  will  be 
followed  by  urination.  An  enema  often  causes  the  child  to 
pass  water,  but,  of  course,  this  may  be  mixed  with  the  stool. 
Letting  the  child  sit  upon  something  cold,  as  a  saucer  or  plate, 
may  cause  her  to  urinate.     Massage  over  the  bladder  is  fre- 


CLINICS  305 

quently  successful.  A  rubber  glove  may  be  used.  An  in- 
genious apparatus  by  Dr.  James  Leach,  one  of  the  fellows  at 
our  hospital  (Fig.  37). 


End  View 
Nipple  Shaped  for 
Glass  Tubing  Application 

Fig.  37. 

This  device  consists  of  a  rubber  nipple  from  a  nursing  bottle, 
a  suitably  curved  piece  of  glass  tubing,  about  three  feet  of  soft 
rubber  tubing,  and  some  adhesive  plaster. 

The  nipple,  preferably  an  old  discarded  one,  because  of  its 
softness,  is  cut  curved,  forming  a  concave  end,  with  the  lower 
portion  forming  a  tongue-shaped  cup.  The  other  end  is  fastened 
to  the  glass  tubing.  This  tubing  is  curved  so  as  to  fit  between 
the  thighs,  and  rests  on  the  bed,  preventing  dragging,  forming  a 
ready  exit  for  the  urine,  and  preventing  backing  up  and  leakage. 
The  rubber  tubing  carries  the  urine  to  a  receptacle  attached  at 
the  side  of  the  bed,  and  the  whole  is  held  in  place  by  means  of 
adhesive  plaster. 

In  applying  the  apparatus  the  labia  majora  are  retracted, 
the  lower  cup-shaped  portion  is  applied  just  within  the  fourchet, 
and  the' rest  is  brought  up,  inclosing  the  labia  minora  and  ure- 
thral orifice  ^\^thin  the  nipple.  The  labia  majora  are  then 
closed  over  this  and  held  together  with  adhesive  plaster.  The 
whole  device  is  further  secured  to  the  vulva  by  means  of  a  fiange- 
shaped  piece  of  adhesive  wrapped  around  glass  tubing. 

Diagnosis.— -Time,  this  morning,  prevents  our  going  into  an 
extensive  discussion  of  the  diagnosis.  I  believe  the  great  ma- 
jority of  men  will  tell  you  that  babies  fed  everj-  two  to  three 
hours  are  suffering  from  overfeeding.  Personalh',  as  regards 
this  point,  I  am  somewhat  of  a  heretic.  Understand,  however, 
20 


306  INFANT   FEEDING    (CHICAGO   METHODS) 

that  many  pediatricians  will  not  agree  with  what  I'm  about  to 
tell  you.  I  believe,  nevertheless,  that  many  children  who  are 
nursed  everj'^  two  to  three  hours  really  are  underfed.  I  believe 
that  they  are  nursed  so  frequently  because  the  mother  hasn't 
sufficient  breast  milk,  and  tries  to  ease  the  child's  discomfort 
by  placing  him  more  frequently  to  the  breast.  I  believe,  in 
these  cases,  if  we  add  food  rather  than  reduce  it,  we  get  better 
results.  The  first  thing,  however,  is  to  determine  definitely 
whether  the  child  is  receiving  too  httle  or  too  mucl\.  The  his- 
tory of  discomfort,  the  failure  to  gain,  the  constipation,  the 
refusal  of  the  child  to  take  the  breast,  all  point  to  insuflficiency 
of  the  supply  of  milk,  and  we  make  a  tentative  diagnosis  of 
inanition. 

Treatment. — Mother,  I  wish  you  would  place  this  baby  to  the 
breast  regularly  every  three  hours — seven  times  in  twenty-four 
hours:  First  at  6  o'clock  in  the  morning,  then  at  9,  12,  3,  6,  9, 
and  once  during  the  night.  If  the  baby  won't  nurse,  give  him 
absolutely  nothing  until  the  next  nursing  time.  Let  him  nurse 
for  twenty  minutes.  Under  no  circumstances  give  him  any 
more  sugar  water.  Bring  him  back  to  us  next  week.  We'll 
weigh  him  accurately,  and  then  shall  know  just  exactly  what  he 
is  doing  on  your  breast  milk.  Be  very  careful  to  give  him 
nothing  in  addition  to  the  breast,  and  be  absolutely  sure  to 
come  next  week.     Good-by! 

Discussion. — Gentlemen,  in  private  practice  we  wouldn't 
wait  so  long  for  the  reaction, — that  we  could  determine  within  a 
few  days, — but  as  these  chnics  are  held  only  once  a  week,  I 
think  it  will  be  desirable  to  wait  to  demonstrate  the  changes. 
I  feel  quite  confident  that  this  baby  will  not  gain  and  that  we 
shall  have  to  add  something  to  the  diet  in  addition  to  the  breast 
milk.  In  all  children  who  are  to  come  we  necessarily  must  wait 
one  week  for  the  reaction,  but  remember,  in  private  practice 
don't  wait  over  two  or  three  days. 

CLINIC  n.— BABY  1 

Age. — Four  months  two  weeks. 

Mother  says  the  baby  is  no  better.  He  frets  after  each  nurs- 
ing, seems  peevish  all  the  time,  and  very  hungry.  He  suffers 
greatly  with  colic  and  is  constipated. 


CLINICS  307 

Question. — After  he  has  finished  nursing  does  he  still  fret? 

Answer. — Yes;  he  never  seems  satisfied  at  the  breast,  and 
I  have  a  terrible  time  making  him  wait  until  the  full  three  hours 
are  up,  but  when  he  gets  to  the  breast  he  doesn't  like  it. 

Question. — Have  you  kept  him  regularly  on  the  three-hour 
schedule? 

Answer. — Yes ;  but  it's  been  very  difficult. 

Weight. — Eleven  pounds  two  ounces.  No  gain  during  the 
week. 

Temperature. — 98°  F. 

Examination. — He  presents  just  exactly  the  same  appearance 
as  last  week.  He's  a  little  flabby  and  pale  and  apparently 
undernourished. 

Discussion. — As  he  hasn't  gained  this  week,  and  in  the  ab- 
sence of  any  factor  other  than  food,  we  feel  sure  of  our  diagnosis 
of  inanition.  I  should  add  a  bottle  right  now,  but  just  to  be 
absolutely  sure  that  mother  is  secreting  an  insufficient  supply  of 
milk  let's  wait  a  few  days  longer.  You  remember  that  this 
child  drank  sugar  water  between  meals.  Possibly  he  was  so 
spoiled,  due  to  the  sweet  taste  of  the  water,  that  for  this  reason 
he  has  refused  the  breast. 

Directions.^ — Let's  try  him  just  one  week  more,  and  then,  if  he 
doesn't  gain,  we  certainly  shall  be  justified  in  adding  a  bottle. 
There  is  a  bare  possibility,  though,  that  by  adhering  rigidly  to 
our  routine  the  child  will  nurse  vigorously  enough  to  increase 
the  supply  of  breast  milk.  Be  sure  to  come  back  next  week, 
mother. 

Question  by  Mother. — But  doctor,  what  shall  I  do  for  the  colic? 
Shall  I  have  my  breast  milk  examined? 

Answer. — All  right,  mother,  give  Dr.  Meadows  a  specimen 
of  your  breast  milk. 

Discussion. — Gentlemen,  you  have  heard  about  quaHtative 
changes  in  breast  milk,  but  examination  will  make  mother  feel 
easier.  Personally,  I'm  convinced  that  this  colic  is  due  to 
hunger,  as  the  child  hasn't  gained  the  required  amount.  How- 
ever, to  make  sure,  let's  wait  another  week  and  see  exactly  what 
he's  doing. 

To  Mother. — I  think  we  can  aid  the  baby  greatly  if  you'll 
just  follow  our  instructions  for  this  next  week.      See  if  you 


308  INFANT   FEEDING    (CHICAGO   METHODS) 

can't  put  up  with  his  crying  for  a  few  days  and  then  we'll  fix 
him. 

Question  by  Dr.  Summerell. — Have  you  any  babies  of  your 
own,  doctor? 

Answer. — No;  but  I  see  by  your  smile  that  you  think  my 
ideas  will  change. 

Dr.  Woodson. — Doctor,  it's  all  very  well  in  clinic  to  tell  these 
mothers,  "  If  baby  is  crying,  let  him  alone,"  but  we  can't  do  that 
in  practice.  When  we  are  called  up  at  3  a.  m.  and  father  says, 
wearily,  "I  never  knew  I  could  walk  ten  thousand  miles  in  one 
evening,"  we've  got  to  say  something  more  to  him  than  simply 
"weigh  the  baby." 

Answer. — Gentlemen,  I  accept  the  reproof.  The  reason  I 
didn't  lay  much  stress  upon  the  colic  is  my  earnest  desire  to 
teach  you  to  put  the  welfare  of  the  baby  above  the  relief  of  any 
individual  symptom.  As  regards  the  immediate  rehef  of  coHc, 
an  enema  may  save  the  day,  or,  rather,  the  night.  The  enema 
can  be  given  in  the  form  of  salt  solution, — a  teaspoon  of  salt  to  a 
pint  of  water, — or,  if  this  is  not  satisfactory,  as  a  soapsuds  enema. 
One  drop  of  essence  of  peppermint  in  a  teaspoonful  of  sweetened 
water,  by  causing  internal  warmth,  will  sometimes  satisfactorily 
relieve  pain ;  or  you  may  give  a  few  drops  of  pepsin.  Apply  hot- 
water  bags  or  hot  flannels  to  the  abdomen,  and  lastly,  if  the  child 
mu^t  be  relieved,  give  him  a  few  drops  of  paregoric,  and  repeat  in 
an  hour  or  so.  But,  gentlemen,  the  point  to  be  remembered  is 
this:  While  advising  this  treatment,  always  ask  yourselves,  "  Is 
this  truly  a  case  of  intestinal  colic?"  Don't  neglect  to  apply  a 
Uttle  pressure  to  the  ear;  don't  neglect  to  ask  for  a  urinalysis 
as  soon  as  possible.  The  colic,  after  all,  may  be  simply  an  otitis 
media,  a  cystitis,  or  a  meningitis.  Second,  ask  yourselves,  "Is 
this  truly  a  case  of  colic  from  indigestion,  or  is  it  simply  the  pain 
of  hunger?"  For  this  latter  reason  I  lay  so  much  emphasis  on 
the  weight.  Lastly,  if  it's  a  digestive  affair,  is  it  due  to  too  much 
perfectly  good  food  or  is  it  due  to  an  excess  of  one  individual 
element  of  a  food?  We  think  that  some  colic  in  the  breast  fed 
is  due  possibly  to  excessive  carbohydrate  in  the  breast  milk. 
So,  gentlemen,  although  the  relief  of  the  immediate  pain  in  a 
child  is  important  and  not  difficult,  don't  forget  that,  after  all, 


CLINICS  309 

the  essential  thing  is  to  arrive  at  the  underlying  factor  and  make 
a  proper  diagnosis. 

Question  by  Dr.  F.  Raymond  Taylor  (High  Point). — Doctor, 
as  long  as  we  are  on  the  subject,  would  you  mind  telling  us  just 
what  is  three  months'  colic? 

Answer. — Three  months'  cohc  is  a  term  applied  by  the  laity 
to  the  colic  which  occurs  in  breast-fed  babies  who  seem  thriv- 
ing, however,  in  every  way.  It  lasts  usually  from  three  to  six 
months,  the  baby  suffering  apparently  from  considerable  in- 
digestion, and  showing  green,  watery,  fermentative  stools. 
The  etiology  is  not  definitely  known.  I  don't  know  of  much 
scientific  work  upon  it,  as  the  condition  is  not  of  grave  signifi- 
cance; the  children  all  outgrow  it.  Two  factors  may  be  con- 
cerned: First,  some  evidence  points  to  the  fact  that  it  occurs  in 
nervous  children — that  it  is  due  not  to  the  milk,  but  to  the  baby. 
These  neuropathic  children,  for  some  reason  or  other,  do  not 
seem  able  to  control  fermentative  processes  in  the  intestine  as 
do  normal  children.  The  second  factor,  although  not  proved, 
might  lie  in  an  excess  of  sugar  in  the  mother's  milk.  Certainly 
the  stools  of  these  children  point  to  fermentation. 

The  practical  treatment  of  the  colic,  in  which  you  gentlemen 
have  shown  yourselves  so  interested,  is  along  the  lines  just  laid 
out.  To  strike  at  the  cause,  however,  we  attempt  to  overcome 
intestinal  fermentation.  This  can  be  done  by  giving  a  little 
powdered  casein  or  powdered  curds  of  milk  after  each  nursing, 
or,  by  what  sometimes  works  wonders,  namely,  a  little  albumin 
milk  with  no  sugar,  after  the  breast.  This  food,  with  its  high 
protein,  low  salt,  and  low  carbohydrate,  by  tending  to  stimu- 
late putrefaction  in  the  intestine,  sometimes  accompUshes  sur- 
prising results. 

In  this  case  I'm  positive  that  the  crying  is  from  hunger.  In 
private  practice  I  should  have  added  a  bottle  to  the  diet  several 
days  after  first  seeing  the  child,  but,  unfortunately,  the  clinics 
come  only  weekly,  and  I'm  very  anxious  to  show  you  the  differ- 
ent reactions  of  the  weight  curve  uninfluenced  by  treatment. 
In  this  case  the  curve  has  remained  horizontal,  so  we'll  make 
mother  put  up  with  the  noise  just  one  week  more. 


310  INFANT  FEEDING    (CHICAGO   METHODS) 


CLINIC  in.— BABY  1 

Age. — Four  months  three  weeks. 

Mother  says  the  child  has  not  improved  in  any  way,  is  still 
fretful,  peevish,  irritable,  and  doesn't  take  the  breast  well  at  all. 
No  additional  symptoms  or  complications  have  been  noted. 
Bowels  are  constipated.  Mother  says  that  she  hasn't  much 
milk,  and  the  baby  cries  all  the  time.  In  addition,  the  child 
shows  some  aversion  to  the  breast  and  is  not  nursing  well. 

Weight, — Ten  pounds  fourteen  ounces,  showing  a  loss  of  four 
ounces  during  the  week. 

Temperature.— 97.8°  F. 

Question. — Mother,  do  you  notice  that  your  supply  of  milk  is 
much  less  than  it  used  to  be? 

Answer. — Yes,  indeed,  the  baby  doesn't  get  much  from  the 
breast  any  more. 

Directions. — To  confirm  our  diagnosis  of  inanition, — this  loss 
is  by  no  means  sharp  enough  to  suggest  any  of  the  graver  dis- 
turbances,— we'll  add  a  bottle  after  each  nursing.  Let's  figure 
that  the  baby  will  drink  about  two  ounces,  and  so  if  he's  four 
and  one-half  months  old  we'll  be  absolutely  safe  in  ordering  a 
mixture  of — 

Milk 9  ounces 

Water 6  ounces 

Sugar 4  teaspoonfuls 

Seven  bottles. 

To  Mother. — Mother,  have  you  ever  fixed  up  any  feedings 
before? 

Answer. — No. 

Well,  then,  let  me  tell  you  just  exactly  how  to  proceed:  In 
one  corner  of  the  kitchen  put  up  a  shelf,  or  else  set  aside  a  corner 
of  the  kitchen  table.  Use  this  exclusively  for  baby's  food  uten- 
sils, and  don't  mix  them  with  anything  else  in  the  kitchen. 
First,  get  as  many  bottles  as  there  are  feedings  during  the  day, 
or  even  a  few  more.  Next  take  some  whole  milk,  shake  it 
thoroughly  so  that  the  cream  is  well  mixed,  and  in  your  case 
pour  out  nine  ounces.  Add  six  ounces  of  water  and  four  tea- 
spoons of  sugar.     Boil  thoroughly  for  a  minute  and  pour  at 


CLINICS  311 

once  into  seven  bottles.  This  makes  about  two  ounces  in  each. 
If  you  let  the  mixture  stand  in  an  open  pitcher  for  any  length  of 
time,  it  will  spoil. 

Get  a  few  cents'  worth  of  sterile  cotton  and  cork  the  bottles, 
keeping  the  unused  cotton  in  its  original  package.  Then  you 
are  through  for  the  day.  Of  course,  you  must  keep  the  bottles 
cool,  either  in  the  ice-box  or,  if  you  haven't  one,  in  the  well  or 
in  the  stream. 

Nurse  the  baby  for  ten  to  fifteen  minutes  and  then  give  a 
bottle.  Let  him  have  this  five  or  ten  minutes.  If  he  takes  it 
and  is  satisfied,  well  and  good;  but  if  he  doesn't  finish  it  in  ten 
minutes,  take  it  away  from  him.  By  all  means  nurse  him  first 
and  give  the  bottle  afterward,  because  if  you  give  the  bottle 
first,  he  will  wean  himself  more  easily.  This  way  will  be  more 
likely  to  keep  up  your  milk  supply. 

Put  the  nipple  on  the  bottle  only  at  feeding  time.  Those  not 
in  use  can  be  kept  in  a  covered  jar  of  boiled  water  with  a  little 
boric  acid  or  soda. 

As  regards  washing  the  bottles :  you  may  do  so  either  at  once 
or  the  next  morning.  If  the  latter,  because  milk  sticks  to  the 
inside,  get  a  bottle  brush,  scrub  them  with  yellow  soap,  and 
rinse  them  thoroughly  afterward.  If  you  wash  them  directly 
after  using,  keep  the  clean  bottles  in  a  jar  with  sterile  water  and 
a  little  soda.  When  you  clean  the  nipples,  be  sure  to  invert 
them.  It  goes  without  saying  that  if  the  baby  drops  his  bottle 
on  the  floor  you  must  take  out  another  nipple. 

When  you  give  the  baby  his  bottle,  be  sure  to  see  that  he 
really  gets  it.  Don't  leave  him  all  alone  to  go  to  sleep,  but  do 
your  best  to  hold  it  and  give  it  to  him  with  the  same  care  that 
you  would  if  you  were  nursing  him.  Hold  the  bottle  so  that  he 
really  gets  milk,  not  air. 

Warm  the  bottle  just  before  giving  it  to  him  by  putting  it  in 
a  little  warm  water,  but  if  you  take  the  baby  out  for  the  day, 
don't  make  the  mistake  of  heating  the  bottle  before  you  go. 
Wait  until  feeding  time  or  else  the  milk  will  spoil.  You  can  do 
a  good  deal  toward  keeping  the  bottle  cool  by  wrapping  it 
thoroughly  in  a  newspaper  before  you  go  out. 

Let's  see  him  again  next  week,  and  when  you  come  back  tell 
us  how  he  is.     We'll  weigh  him  and  see  how  he  has  responded. 


312  INFANT  FEEDING    (CHICAGO   METHODS) 

Question. — Have  you  understood  everything,  mother? 

Mother.— li  I  am  to  give  seven  bottles  with  two  ounces, 
should  I  add  five  or  six  ounces  of  water? 

Answer. — Six  ounces,  because  about  one  will  be  lost  during  the 
boiling. 

Discussion. — It's  always  a  good  idea  to  add  more  water  than 
you  need  on  account  of  the  boiling.  You  notice  the  simplicity 
of  the  formula?  It  required  no  calculation  on  my  part  what- 
soever. It  consists  simply  of  two-thirds  milk  and  one-third 
water,  with  a  httle  sugar. 

In  cases  such  as  this  I  prefer  to  add  a  bottle  after  each  nursing, 
but  when  such  order  works  hardship  on  a  mother  who  is  weak 
or  who  must  work,  we  may  give  breast  and  bottle  in  alternate 
feedings. 

Whenever  I  order  a  bottle  I  start  orange-juice.  You  may 
dilute  it  with  water,  or  give  haK  a  teaspoon  of  the  pure  juice. 
In  either  case  the  baby  may  vomit  the  first  dose  or  have  a  little 
colic.  Don't  pay  any  attention  to  these  symptoms,  but  give  it 
again  the  next  day,  and  in  a  short  time  you'll  find  baby  taking 
it  nicely. 

CLINIC  IV.— BABY  1 

Age. — Five  months. 

Baby  is  very  much  better.  He  takes  his  bottle  after  each 
nursing  and  likes  it  ever  so  much.  He  vomits  just  a  little  bit, 
but  sleeps  through  the  night  now.  He  is  quiet  for  three  hours 
and  seems  a  different  baby. 

Weight. — Eleven  pounds  eight  ounces,  a  gain  of  ten  ounces  in 
a  week. 

Temperature. — 98°  F. 

Examination. — The  child  certainly  looks  better  and  happier 
and  begins  to  have  the  contented  look  of  the  normal  baby. 

Discussion. — With  such  a  nice  response  of  the  weight  we  ig- 
nore absolutely  the  vomiting.  The  baby's  general  nutrition, 
which  is  the  point  in  which  we  are  interested,  has  certainly  im- 
proved. 

Directions. — Mother,  keep  up  this  treatment  and  let's  see  him 
again  in  a  week. 


CLINICS  313 


CLINIC  v.— BABY  1 

Age. — Five  months  one  week. 

Mother  says  the  baby  is  doing  nicely,  but  that  he  is  a  little 
hungry;  that  no  sooner  does  he  empty  his  bottle  than  he  cries 
for  the  next  one. 

Weight. — Eleven  pounds  fifteen  ounces,  showing  a  gain  of 
seven  ounces  during  the  week. 

Temperature. — 98.6°  F.  * 

Examination. — Child  looks  bright  and  happy. 

Discussion. — I  don't  think  we  can  complain  of  that  gain  in 
weight,  and  I  should  advise  the  mother  to  let  him  absolutely 
alone.     He  is  gaining  really  faster  than  he  should. 

Mother  says:  "That  is  all  right,  doctor,  but  I  have  no  breast 
milk.  For  the  last  week  my  breast  milk  has  gone  entirely,  and 
to  tell  the  truth,  I  have  given  him  more  of  the  bottle  myself." 

Directions. — Well,  that's  different.  We'll  put  him  on  regular 
bottle  feedings  for  a  baby  of  his  age.  He's  over  four  months 
old,  so  we'll  order — 

Milk 20  ounces 

Water 11  ounces 

Sugar 6  teaspoonf uls 

Five  feedings  and  start  a  little  cereal. 


CLINIC  Vm.— BABY  1 

Age. — Six  months. 

Mother  says  the  baby  did  all  right  for  a  week,  but  for  the  last 
two  has  been  hungry  and  not  gaining. 

Weight. — Twelve  pounds  eight  ounces,  showing  a  gain  of  nine 
ounces  in  three  weeks. 

Temperature.— ^^.^"^  F. 

Examination  shows  him  to  be  in  good  condition. 

Directions. — Mother,  baby  is  now  six  months  old;  so  you 
gradually  may  offer  a  greater  variety  of  food.  Very  slowly  add 
a  little  soup  or  vegetable  or  chicken  broth.  Give  an  occasional 
Graham  cracker  or  a  little  zwieback,  which  is  the  same  as  hard, 
dry,  doubly  baked  bread.  If  you  can't  get  it,  take  some  toast 
and  bake  it  thoroughly  until  very  hard  and  dry.     Give  the 


314  INFANT  FEEDING    (CHICAGO   METHODS) 

zwieback  or  Graham  cracker  mashed  up  with  a  Uttle  broth,  or 
soaked  in  the  soup  or  the  bottle,  or  baby  may  like  to  take  it  in 
his  hand  and  chew  it.  In  addition  to  these,  start  a  variety  of 
cereals,  such  as  farina,  corn-starch,  Cream  of  Wheat,  or  arrow- 
root. 

We  can  begin  with  vegetables :  you  may  use  almost  any  that 
can  be  boiled  to  soft  consistence,  put  through  a  sieve,  and  made 
into  a  pur^e.  This  includes  mashed  potatoes.  Perhaps  the 
best  at  first  is  spinach  or  carrots.  Carrots  are  best  given  if 
cooked  and  then  grated  right  into  the  soup. 

Of  course,  the  baby  must  have  fruit-juices,  such  as  orange- 
juice,  prune-juice,  and  also  a  little  apple-sauce  or  baked  apple. 
A  six-months-old  baby  may  have  a  strip  of  bacon.  Bacon 
directly  from  the  shop  is  a  little  salty;  so  it's  a  good  idea  to  soak 
it  first  in  water  to  rid  it  of  this  excess,  and  then  broil  it  rather 
crisp.     You  may  start,  too,  with  beef -juice. 

Question  by  Mother. — How  shall  I  cook  the  cereal? 

Answer. — If  you  are  using  farina,  take  a  tablespoonful  to  a 
cup  of  water;  boil  this  over  the  fire  for  half  an  hour.  As  the 
water  boils  away,  of  course,  add  fresh  water.  In  the  last  few 
minutes  add  about  half  a  cup  of  milk.  You  must  stir  this  con- 
stantly; if  you  use  a  double  boiler,  you  won't  need  to  use  so 
much  care,  but  you  must  cook  it  for  over  four  hours.  Add  a 
pinch  of  salt  and  enough  sugar  to  sweeten  slightly.  In  making 
corn-starch  I  would  use  perhaps  a  little  less  than  a  tablespoonful 
because  the  corn-starch  thickens  easily. 

Question  hy  Mother. — We  don't  have  farina  down  here;  I 
never  heard  of  it,  but  could  we  use  hominy  or  a  little  mush  in- 
stead? 

Answer. — Yes,  those  would  do  exactly  as  well. 

Question  hy  Mother. — How  about  oatmeal? 

Answer. — Some  children  take  oatmeal  very  well  at  six  months, 
but  to  some  it  seems  rather  laxative.  Of  all  cereals,  oatmeal 
seems  most  Ukely  to  ferment  and  cause  diarrhea  in  children  of 
this  age. 

Question  hy  Mother. — How  shall  I  prepare  the  beef-juice? 

Answer. — Cut  the  beef  into  tiny  cubes,  throw  them  into  a  hot 
pan  to  sear  the  outside,  and  then  squeeze  out  the  juice.  You 
may  give  a  teaspoonful  or  more  a  day. 


CLINICS  315 

Question  hy  Dr.  Meadows. — Would  you  use  fresh  or  canned 
vegetables? 

Answer. — If  possible,  I  would  certainly  use  the  fresh.  By 
the  way,  if  you  have  any  trouble  in  making  pur^e,  we  have  a 
little  apparatus  in  the  hospital  at  home  which  is  of  great  value. 
It's  a  little  grinding  mill  put  up  by  the  Enterprise  Manufactur- 
ing Co.,  of  Philadelphia,  called  the  "Nixtamal  Mill."  It's  in- 
expensive, costing  only  a  few  dollars,  and  certainly  is  very  satis- 
factory. Dr.  Abt  introduced  it  into  our  hospital,  trying  it  as  a 
means  for  pulverizing  casein  and  curds  in  the  making  of  albu- 
min milk. 

Of  course,  in  starting  the  baby  out  don't  give  him  a  banquet 
the  very  first  day.  You  must  use  considerable  discretion  and 
care.  I  think  I  should  start  out  perhaps  like  this:  Tomorrow, 
after  the  10  o'clock  bottle,  add  a  half  teaspoonful  of  the  farina 
or  corn-starch.  This  being  a  new  food,  may  be  vomited;  don't 
pay  any  attention  to  this  vomiting,  but  repeat  the  next  day. 
Gradually,  day  by  day,  increase  the  dose,  so  that  by  the  end  of 
two  or  three  weeks  he  gets  the  whole  quantity.  A  few  days 
after  giving  the  cereal  start,  in  addition,  one  of  the  other  foods, 
as  a  little  broth  or  a  teaspoonful  of  vegetable  puree  after  the 
2  o'clock  bottle.  A  few  days  later,  having  increased  the  quan- 
tity of  broth  to  an  ounce  or  more,  try  a  few  crumbs  of  zwieback 
broken  into  the  broth.  In  two  or  three  weeks,  when  you  have 
learned  which  foods  baby  prefers,  give  him  at  2  o'clock  a  little 
dinner  of  broth,  zwieback,  a  little  vegetable  and  beef-juice,  or 
bacon.  Then,  of  course,  he  won't  take  so  much  of  his  bottle; 
but  remember,  it's  essential  to  start  gradually  and  increase  very 
slowly.  As  baby  is  getting  small  amounts  of  food  the  first  few 
days,  he  won't  gain  much,  and  we  must  tell  mother  in  advance, 
so  that  she  won't  be  discouraged  if  there  isn't  a  marked  gain 
next  week. 

Question  hy  Dr.  Brown. — Don't  you  think,  doctor,  this  is  a 
pretty  full  diet  for  so  young  a  baby? 

Answer. — I  suppose  it  seems  that  way;  I  doubt  if  you  will 
find  it  prescribed  in  many  texts.  On  the  other  hand,  if  you 
will  only  try  it  as  I  have  outlined,  I  am  sure  you  will  agree  with 
me  that  it  is  very  successful.  I  have  had  many  discussions  and 
been  forced  to  overcome  many  objections,  particularly  from  the 


316  INFANT  FEEDING    (CHICAGO   METHODS) 

nurses,  but  I  believe  you  will  find  that  such  a  diet  will  be  adopted 
more  and  more.  Certainly  the  brilliant  results  we  get  at  home 
are  sufficient  evidence  in  its  favor.  From  my  own  point  of 
view  I  believe  that  our  fear  of  overfeeding  babies  has  carried  us 
to  the  other  extreme,  and  that  many  babies  of  this  age  really 
are  underfed.  Of  course,  I  don't  mean  that  you  should  cram 
food  into  a  child  and  stuff  him :  simply  give  him  what  he  wants 
and  you  will  find  that  upon  the  four-hour  schedule  he  adjusts 
his  diet  to  his  own  needs  and  practically  never  overfeeds  him- 
self. Of  course,  you  must  remember  that  as  he  takes  more 
solid  food  he  drinks  less  of  his  bottle;  so  don't  force  the  bottle 
upon  him.  And  remember  that  his  daily  diet  shouldn't  contain 
everything  in  this  list,  but  just  should  be  selected  from  it. 

Question  by  Mother. — Can  I  add  an  egg? 

Answer. — No,  I  should  not  advise  this  as  yet.  It  is  true  that 
some  children,  as  early  as  the  eighth  or  ninth  month,  take  a  soft- 
boiled  egg  and  tolerate  it  well,  but  it  is  wiser,  with  the  majority 
of  children,  to  wait  imtil  they  are  somewhat  over  a  year. 


CLINIC  Vn.— BABY  1 

Age. — Six  months  one  week. 

Mother  says  the  diet  is  causing  diarrhea.  She  has  given  a 
little  spinach,  and  he  hkes  it  very  much.  He  seems  happy  and 
sleeps  well,  but  has  a  diarrhea,  with  four  or  five  watery  stools 
daily. 

Weight. — Twelve  pounds  ten  ounces,  a  gain  of  two  ounces  in  a 
week. 

Temperature.— 98.Q°  F. 

Examination. — ^Well,  gentlemen,  he  looks  well,  doesn't  he? 
Notice  he  seems  happy,  contented,  smiling,  and  he  kicks  and 
stamps  and  waves  his  arms.  He's  interested  in  everything 
about  him,  so  no  matter  what  mother  tells  us  about  his  bowels, 
the  baby  looks  all  right,  and  the  gain  in  weight,  though  slight, 
proves  this.  Probably  he  hasn't  eaten  enough  to  cause  a  greater 
gain. 

Discussion. — In  many  cases  diarrheas  occurring  upon  addi- 
tion of  solid  food,  though  attributed  to  the  diet,  depend  upon 
absolutely  other  factors. 


CLINICS  317 

Question. — Mother,  have  you  been  feeding  the  baby  as  we 
told  you? 

Answer. — I  started  in  very  slowly  and  carefully,  and  he  is 
getting  just  a  little  cereal,  broth,  and  yesterday  some  spinach. 

Question.— How  long  have  the  bowels  been  loose? 

Answer. — Three  days. 

Question. — Have  you  given  any  medicine? 

Answer. — Yes.  I  was  afraid  he  wouldn't  digest  the  cereal 
very  well,  and  so  I  gave  him  three  teaspoons  of  castor  oil  for  the 
last  three  days. 

Discussion. — No  more  explanations  are  necessary,  gentlemen. 
The  castor  oil  explains  the  diarrhea. 

A  nice  illustration  of  diarrhea  occurring  upon  change  of  diet 
is  one  I  saw  yesterday.  The  baby,  one  year  old,  was  brought 
for  feeding.  He  had  been  breast  fed  until  three  weeks  before. 
We  ordered  a  soft  diet  and  a  milk  mixture  of — 

Milk 20  ounces 

Water 11  ounces 

Five  feedings. 

We  told  mother  to  wean  him  gradually. 

On  his  return  mother  reported  a  diarrhea,  which  she  ascribed 
to  the  soft  diet.  Questioning  revealed  that  in  trying  to  wean  the 
baby  she  had  put  salt  on  her  nipples  to  make  them  distasteful. 
The  baby  liked  this  addition  and  took  to  it  eagerly;  so  the  in- 
genious mother  added  pepper.  This  combination  proved  too 
much,  and  the  diarrhea  resulted. 


CLINIC  Vin.— BABY  1 

Age. — Six  months  two  weeks. 

Mother  says  'the  baby  is  well  in  every  respect — the  bowels 
move  two  to  four  times  a  day.  He  likes  his  vegetables,  and  is 
content  and  happy. 

Weight. — Thirteen  pounds  one  ounce,  a  gain  of  seven  ounces 
in  the  week. 

Discussion. — You  see,  gentlemen,  what  one  accompUshes  by 
judicious  use  of  a  soft  diet.     Let's  let  him  alone. 

Mother,  you  might  bring  him  back  in  two  or  three  weeks. 


318  INFANT   FEEDING    (CHICAGO  METHODS) 

CLINIC  I.— BABY  2 
Dr.  J.  D.  Williams   (Greensboro) 
Age. — Five  weeks. 

History.— l^egative.  Mother  has  no  breast  milk  and  comes 
for  feeding  advise. 

Temperature.— 9S.S°  F. 
Weight. — Seven  pounds  three  ounces. 
Examination. — Normal  baby. 
Directions. — 

Milk 11  ounces 

Water 11  ounces 

Sugar 4  teaspoonf  uls 

Seven  feedings. 

Don't  omit  orange-juice. 
Let's  see  the  baby  next  week. 

CLmiC  n.— BABY  2 

Age. — Six  weeks. 

Mother  says  the  baby  is  not  doing  well ;  that  he  cries,  doesn't 
want  to  eat,  has  colic,  and  is  awfully  constipated.  The  food 
doesn't  agree  with  him.  He  doesn't  even  empty  his  bottles, 
and  his  mouth  is  very  sore  and  all  white. 

Temperature. — 99.4°  F. 

Weight. — Seven  pounds  four  ounces,  showing  a  gain  of 
one  ounce  in  the  week. 

Examination. — Negative,  except  for  white  patches  all  over 
gums  and  mucous  membrane  of  the  cheeks. 

Discussion. — Gentlemen,  you  see  the  value  of  our  scales. 
This  week  the  child  gained  only  one  ounce — an  insufficient  gain, 
of  course.  Can  this  be  due  to  an  acute  disturbance  from  overr 
feeding?  No,  because  there  is  no  acute  loss  in  weight — simply 
failure  to  gain.  There  is  no  diarrhea;  indeed,  the  baby  is  very 
constipated.  It's  more  likely  that  the  pain  is  that  of  hunger, 
and  that  the  failure  to  gain  is  from  insufficient  food. 

Diagnosis. — We  diagnose  mild  inanition,  and  ask,  "  Why  isn't 
he  drinking  his  full  bottle?"  Is  it  because  he  doesn't  hke  it? 
Is  it  because  he  has  bronchitis,  or  something  interfering  with  his 


CLINICS  319 

drinking?  Our  examination  has  answered  this  question  at  a 
glance. 

Question. — Mother,  you've  been  washing  out  the  baby's 
mouth.     What  have  you  used? 

Answer. — The  druggist  recommended  some  silver  nitrate  to 
me. 

Discussion. — See  how  a  little  disturbance  absolutely  inde- 
pendent of  food  may  arise,  and  lead  you,  if  not  careful,  to  diag- 
nose improper  feeding!  Here  is  an  excellent  illustration  of 
thrush  and  the  improper  way  of  treating  it.  Thrush,  you  know, 
is  an  infection  by  a  fungus.  The  fungus  never  attacks  an  in- 
tact mucous  membrane,  but  only  one  that  has  been  injured. 
The  surest  way  of  predisposing  the  child  to  infection  is  to  wash 
the  mouth  with  any  strong  solution  or  with  sufficient  mechanical 
violence  to  cause  injury.  Remember,  the  intact  mucous  mem- 
brane is  immune.  During  my  experience  in  the  Finkelstein 
clinic  we  could  tell  at  a  glance  from  which  maternity  hospital 
our  patients  came.  All  those  who  had  thrush  came  from  an 
institution  where  it  was  routine  to  wash  the  babies'  mouths. 
Those  without  thrush  came  from  one  where  the  mouths  were 
let  alone.  There  is  no  surer  way  of  inviting  thrush  than  to  wash 
out  the  mouth  roughly.     Better  let  it  go  unwashed. 

Directions. — Mother,  for  the  next  few  days  let  the  baby's 
mouth  absolutely  alone.  Once  or  twice  a  day  saturate  a  little 
cotton  with  half  peroxid  and  half  water,  and  just  touch  the  white 
spots  on  the  gums  and  cheeks.  Don't  rub  them  or  scrape  them, 
but  touch  them  as  gently  as  if  you  were  taking  up  a  blot  with  a 
piece  of  blotting-paper.  When  his  mouth  is  healed  and  it 
doesn't  hurt  to  drink,  I  think  he'll  take  his  bottle  better.  For 
the  next  few  days,  as  his  mouth  is  so  sore,  feed  him  with  a  spoon 
or  a  medicine-dropper. 


CLINIC  m.— BABY  2 

Age. — Seven  weeks. 

Mother  says  the  baby  is  drinking  the  bottle  with  renewed 
vigor,  but  that  he's  hungry. 

Weight. — Seven  pounds  five  ounces,  showing  a  gain  of  one 
ounce  in  a  week. 


320  INFANT   FEEDING    (CHICAGO   METHODS) 

Temperature.— 9S.Q°  F. 

Examination  shows  the  mouth  in  much  better  condition. 

Discussion. — As  this  gain  is  insufficient,  and  as  the  baby  now 
is  taking  his  entire  food  as  offered,  the  failure  to  gain  must  be 
due  to  insufficient  amount. 

Directions. — We'll  order  an  increase  to — 

Milk 13  ounces 

Water 12  ounces 

Sugar 6  teaspoonf uls 

Sieven  bottles. 


CLINIC  IV.— BABY  2 

Age. — Eight  weeks. 

Mother  says  baby  is  doing  nicely;  that  he  drinks  well  and 
seems  satisfied.  Until  yesterday  he  had  been  quite  constipated, 
but  yesterday  his  bowels  moved  three  times  and  she  noticed  a 
lot  of  white,  hard  curds  in  the  stool.  The  other  day  he  had  a 
httle  cold. 

Weight. — Seven  pounds  fourteen  ounces,  showing  a  gain  of 
nine  ounces  in  the  past  week. 

Temperature.— 9S.8°  F. 

Examination. — Negative,  other  than  coryza. 

Discussion. — Gentlemen,  as  he  gained  nine  ounces  in  the  past 
week,  we're  not  going  to  worry,  about  the  bowel  trouble.  Un- 
doubtedly it  resulted  from  the  coryza,  with  secondary  fermen- 
tation in  the  intestine,  but  you  see  for  yourselves,  from  the 
happy  appearance  of  the  child  and  from  the  decided  gain,  his 
nutrition  is  in  no  way  affected. 

Question. — Mother,  are  you  boiling  the  milk? 

Answer. — No,  doctor,  I  thought  it  would  be  better  to  give  it 
raw. 

Directions. — Mother,  if  you  will  boil  the  milk  the  hard  curds 
will  disappear  from  the  stool.  Use  a  little  liquid  vaselin  for  the 
nose,  and  when  the  cold  is  better  his  bowels  will  correct  them- 
selves. If  they  don't  in  a  day  or  two,  the  doctor  will  order  some 
chalk  mixture. 


CLINICS  321 

CLINIC  I.— BABY  3 

Dr.  C.  S.  Gilmer  (Greensboro) 

Age. — Seven  weeks. 

History. — Mother  lost  her  milk  and  has  never  nursed  any  of 
her  babies  over  a  few  weeks.     She  comes  for  advice. 

Temperature. — 98.6°  F.     Weight,  seven  pounds  fifteen  ounces. 
Examination  shows  a  happy  baby.     Everything  negative. 
Discussion. — He  has  been  getting — 

Milk 14  ounces 

Water 14  ounces 

Sugar 6  teaspoonfuls 

Seven  feedings. 

This  seems  a  perfect  formula.  You  notice  it's  half  milk  and  half 
water,  and  approximately  3  percent  carbohydrate.  The  total 
quantity  is  a  little  above  the  average  for  babies  of  this  age,  but 
if  he's  taking  it  well  and  not  vomiting,  I  don't  believe  it  needs  to 
be  changed. 

Directions. — Continue  this  formula.  Don't  forget  to  shake 
the  milk  thoroughly  before  making  up  the  mixture,  and  don't 
forget  the  orange-juice. 

CLINIC  II.— BABY  3 

Age. — Eight  weeks.     The  baby  is  fine,  happy,  and  contented 

in  every  way. 

Weight. — Eight  pounds  four  ounces,  showing  a  gain  of  five 
ounces. 

Temperature.— 9S.8°  F. 

Examination. — Negative. 

Directions. — Baby  is  doing  well,  but  you  had  better  bring  him 
next  week. 

Discussion. — Gentlemen,  I  like  to  have  the  babies  return  as 
often  as  possible.  It's  the  best  means  to  keep  a  check  on  them. 
Those  who  don't  return,  puzzle  us:  may  be  the  diet  didn't 
agree  with  them.  On  the  other  hand,  may  be  it  agreed  with 
them  so  well  that  the  mother  thinks  her  troubles  are  over — a 
dangerous  conclusion,  however.     As  I  have  tried  to  emphasize, 

any  baby  upon  the  bottle  is  to  be  regarded  as  sick,  and  I  urge 
21 


322  INFANT   FEEDING    (CHICAGO   METHODS) 

you  to  impress  this  upon  your  patients  and  have  them  return  as 
frequently  as  possible, 

CLINIC  m.— BABY  3 

Age. — Nine  weeks. 

Mother  says  the  baby  seems  to  be  doing  pretty  well  but  is 
hungry.  He  had  a  croupy  cough  for  the  last  two  or  three  days. 
His  bowels  are  constipated,  with  hard  stools. 

Weight. — Eight  pounds  two  ounces.  Loss  of  two  ounces  in 
the  week. 

Temperature.— 'd^. 2°  F. 

Examination. — Very  sUght  bronchitis. 

Question. — Mother,  does  the  baby  vomit  when  he  coughs? 

Answer. — No. 

Question. — Is  his  cough  worse  at  night  or  in  the  daytime? 

Answer. — It's  worse  in  the  daytime. 

Question. — Does  he  whoop  at  all? 

Answer. — No. 

Discussion. — Gentlemen,  in  all  cases  of  coughing  in  children, 
don't  overlook  pertussis.  In  this  case  we're  glad  to  hear  that 
the  stool  is  constipated,  although  the  mother  looks  shocked. 
Children,  especially  the  young  ones,  when  they  develop  coughs 
or  colds,  show  severe  diarrheas  and  nutritional  disturbances. 
The  fact  that  this  child  hasn't  reacted  shows,  first,  that  his 
intestinal  tract  is  unaffected,  and,  second,  that  we  needn't 
fear  increasing  his  diet.  Mother  says  he's  hungry  and  would 
Uke  more.  If,  however,  he  were  having  a  diarrhea  associated 
with  this  cough,  we  certainly  shouldn't  order  an  increase.  The 
weight  shows  a  loss  of  two  ounces  this  week,  yet  the  mother  says 
he  empties  all  his  bottles.  If  he  were  having  a  diarrhea  at  this 
time,  we  might  diagnose  a  mild  dyspepsia.  The  fact  that  he's 
constipated ;  that  he  empties  all  the  bottles  and  still  is  hungry, 
makes  us  believe  that  his  failure  to  gain  is  not  due  to  any  com- 
plication but  simply  to  insufficient  food. 

Directions. — We'll  order — 

Milk 16  ounces 

Water. 16  ounces 

Sugar 7  teaspoonfuls 

Seven  bottles. 


CLINICS  323 

I  warn  you  this  is  rather  daring  for  children  suffering  with  in- 
fections, but  the  fact  that  he  looks  and  acts  perfectly  well — 
notice  his  rosy  color  and  his  pleasant  smile — and  that  he  is 
hungry,  warrants,  I  beheve,  this  increase. 

CLINIC  IV.— BABY  3 

Age, — Ten  weeks. 

Mother  says  the  baby  is  in  fine  condition.  His  bowels  move 
once  a  day,  sometimes  twice. 

Weight. — Eight  pounds  nine  ounces,  showing  a  gain  of  seven 
ounces  in  the  last  week. 

Temperature.— 9S.Q°  F. 

Examination. — Negative. 

Directions. — As  long  as  he  is  gaining  we'll  make  no  change. 

CLINIC  v.— BABY  3 

Age. — Eleven  weeks. 

Mother  says  the  baby  is  in  good  condition,  but  thinks  he  is 
a  little  hungry. 

Weight. — Nine  pounds  one  ounce,  showing  a  gain  of  eight- 
ounces  during  the  week. 

Temperature. — 98.6°  F. 

Examination. — Negative. 

Directions. — As  the  gain  is  surely  normal,  better  make  no 
change  in  the  feeding,  except  from  seven  to  five  feedings,  with- 
out altering  the  total  quantity. 

CLINIC  VI.— BABY  3 

Age. — Three  months. 

Mother  says  the  baby  is  hungry. 

Weight. — Nine  pounds  four  ounces,  showing  gain  of  only  three 
ounces  in  the  week. 

Temperature.— 98.6°  F. 

Examination. — Negative. 

Directions.— As  he  gained  only  three  ounces  this  week,  I  think 
we  are  justified  in  ordering  a  slight  increase  in  diet.  He's  now 
three  months  old.     We  either  may  increase  the  amount  and 


324  INFANT  FEEDING    (CHICAGO  METHODS) 

thus  the  concentration  of  the  milk  exclusively,  or  we  may  in- 
crease the  total  quantity,  leaving  the  concentration  unchanged. 
As  I  Uke  to  limit  the  total  to  a  quart,  I'd  suggest — 

Milk 18  oiinces 

Water 13  ounces 

Sugar 8  teaspoonfuls 

Five  bottles. 

CLINIC  Vn.— BABY  3 

Age. — Three  months  one  week. 

Mother  says  the  child  has  been  crying  all  the  time,  that  his 
bowels  are  "running  off"  about  seven  or  eight  times,  with  lots 
of  mucus  and  curds.  She  thinks  the  increase  in  the  diet  was 
too  much.  He  has  severe  coUc  and  is  not  gaining.  He  doesn't 
want  the  bottle  and  vomits  sometimes. 

Weight. — Nine  pounds  four  ounces.     No  gain  this  week. 

Temperature. — 101°  F. 

Examination  reveals  nothing  except  this — notice  how  pressure 
on  the  tragus  of  the  right  ear  makes  him  wince  and  cry. 

Discussion. — Gentlemen,  in  90  percent  of  cases  by  this  method 
you  can  diagnose  complications  in  the  auditory  canal  or  the 
middle  ear.  Don't  attempt  to  penetrate  the  cranial  cavity, 
but  just  exert  the  mildest  sort  of  pressure.  A  perfectly  normal 
baby  will  pay  no  attention.  A  baby  who  is  crying,  will  con- 
tinue, but  will  do  nothing  else.  This  child,  however,  not  only 
cries,  but  winces  and  jerks  his  head  away  sharply.  We  have, 
then,  either  a  furuncle  in  the  auditory  canal  or  an  otitis  media. 

Examination. — The  otoscope  reveals  an  inflamed  ear-drum. 

Directions. — This  baby  should  see  the  ear  doctor.  And  now 
we  have  a  dyspepsia  and  colic,  not  directly  from  food,  but 
secondary  to  otitis  media.  Shall  we  change  the  diet  in  this 
case?  Not  at  all,  because  although  there  has  been  a  fermenta- 
tion in  the  intestinal  tract,  this  fermentation  has  not  been 
severe  enough  to  interfere  markedly  with  the  child's  nutrition. 
He  is  not  losing  any  weight ;  so,  mother,  for  the  present  let  the 
baby  alone  as  regards  his  diet — let  him  take  what  he  wishes, 
feed  him  regularly,  and  see  an  ear  doctor.  He  won't  want 
much  for  a  few  days  because  he  has  fever;  so  donH  try  to  force 
him.    Use  a  few  drops  of  a  5  to  10  percent  solution  of  carbohc 


CLINICS  325 

acid  in  glycerin  in  that  ear  every  three  to  four  hours  for  a  day  or 
two  until  you  see  the  ear  doctor. 

Use  a  few  drops  of  pepsin  in  a  teaspoonful  of  water  for  'the 
colic. 

CLINIC  Vm.— BABY  3 

Age. — Three  and  one-half  months. 

Mother  says  the  baby  seems  well.  The  ear  trouble  and 
dyspepsia  have  disappeared,  and  he  is  satisfied  and  happy. 

Weight. — Nine  pounds  nine  ounces,  showing  a  gain  of  five 
ounces  in  the  week. 

Temperature. — 98.6°  F. 

Examination. — Negative. 

Directions. — No  change. 

CLINIC  I.— BABY  4 
Dr.  D.  A.  Stanton  (High  Point) 

Age. — Eighteen  months. 

History. — Negative,  other  than  that  the  child  has  been  suffer- 
ing for  six  months  from  repeated  attacks  of  otitis  media. 

Temperature. — 98.6°  F. 

Weight. — Twenty-three  pounds. 

Physical  Examination. — This  shows  a  pasty,  pallid,  rachitic 
child,  who  looks  anemic  and  water-logged,  although  there  is  no 
edema.  There  are  no  adenoids  nor  large  tonsils.  Right  ear 
discharging. 

Discussion.— Gentlemen,  I  am  no  ear  specialist.  However, 
the  child's  general  nutrition  in  a  way  might  account  for  this 
condition.  Of  course,  in  such  a  child  we  must  rule  out  tubercu- 
losis, syphilis,  hookworm,  nephritis,  blood  diseases,  etc.  Let's 
see  if  the  feeding  is  a  factor. 

Question. — Mother,  how  have  you  been  feeding  the  baby? 

Answer. — I  give  him  mostly  milk. 

Question. — Don't  you  give  him  anything  else? 

Answer. — Well,  sometimes  I  give  him  a  little  hominy  or  mush 
or  toast. 

Question. — Anything  else?  No  vegetables,  eggs;  anything 
like  that? 


326  INFANT   FEEDING    (CHICAGO   METHODS) 

Answer. — No,  that  is  all  he  gets;  sometimes  a  few  Graham 
crackers. 

Discussion. — I  think  that  explains  part  of  the  difficulty.  The 
diet  of  milk  and  carbohydrate,  you  remember,  is  the  one  caus- 
ing water-logging  of  the  body,  and  you  remember  we  spoke  of 
the  fact  that  children  such  as  these  seem  to  have  a  lessened  im- 
munity to  disease.  I  am  glad  of  the  opportunity  to  demon- 
strate such  a  case  to  you,  because  here  we  have  a  disturbance  of 
nutrition  not  following  a  parenteral  infection,  but  really  pre- 
disposing to  one. 

Directions. — Let's  refer  the  child  to  the  ear  doctor,  but  in  the 
meantime  get  him  on  a  well-regulated  diet,  and  try  to  increase 
his  general  resistance  and  immunity.  Of  course,  we'll  order 
cod-hver  oil  with  phosphorus. 

CLINIC  I.— BABY  5 
Dr.  A.  C.  Whitaker  (Juhan) 

Age. — Six  months  two  weeks. 

Weight. — Thirteen  pounds  one  ounce. 

Temperature.— 100.Q°  F. 

Examination  shows  coryza,  slight  bronchitis,  and  a  mud- 
colored  skin. 

History. — Negative  up  to  the  present.  Baby  has  gotten  the 
breast  and  a  mixture  of — 

Milk 6  ounces 

Water 7  ounces 

Sugar 3  teaspoonf uls 

Six  bottles. 

For  two  weeks  he  has  had  a  soft  diet.  Mother  thinks  the 
feedings  are  not  agreeing  with  the  baby,  who  for  the  last  few 
days  has  vomited,  had  diarrhea,  with  six  or  seven  stools  a  day, 
and  refused  food.  The  baby  has  lost  seven  ounces  during  the 
week. 

Discussion. — This  sounds  like  a  true  dyspepsia.  Of  course, 
the  loss  of  weight  could  arise  from  insufficient  food,  but  we  ques- 
tion whether  a  child  who  has  been  gaining  normally  up  to  the 
present  would,  all  of  a  sudden,  drop  back  seven  ounces  in  one 
week.     Vomiting,  except  in  extreme  cases,  is  rarely  associated 


CLINICS  327 

with  underfeeding.  Diarrhea  may  be  present  in  inanition,  as 
well  as  in  other  conditions,  but  from  the  general  symptomatol- 
ogy, the  loss  of  weight,  the  vomiting,  the  diarrhea,  and  the 
anorexia,  we  diagnose  dyspepsia.  The  cause  of  the  dyspepsia 
surely  can't  be  the  food  upon  which  the  child  up  to  the  present 
has  been  thriving,  and  we  must  seek  it  in  other  factors. 

Question. — When  did  you  start  the  soft  diet? 

Answer. — About  a  week  ago.     I  gave  a  little  cereal. 

Question. — How  long  has  he  been  coughing? 

Answer. — He  got  sick  about  five  days  ago. 

Question. — When  did  the  diarrhea  start? 

Answer. — It  started  three  or  four  days  ago. 

Question. — Are  his  cough  and  cold  better  or  worse? 

Answer. — The  cough,  I  think,  is  better. 

Discussion. — Here  we  have  a  parenteral  infection  occurring 
with  the  change  in  diet.  The  mother  blames  the  diet.  We 
believe,  however,  that  the  cough  and  cold  predisposed  the  child 
to  a  mild  fermentation  in  the  intestinal  tract,  and  that  the  re- 
action was  just  severe  enough  to  make  us  careful.  In  a  baby  of 
this  age  on  a  soft  diet  secondary  disturbances  are  not  severe. 
In  a  study  some  time  ago*  we  found  that  the  best  dietetic  treat- 
ment for  these  secondary  diarrheas  in  children  on  a  soft  diet 
is  to  let  them  alone  and  not  to  vary  the  diet  too  dogmatically. 

Directions. — In  this  case  the  doctor  will  treat  the  cough  and 
cold  as  he  sees  fit,  and  we'll  leave  the  diet  unchanged.  Let  the 
baby  eat  what  he  wishes.  He  won't  eat  very  much  for  a  few 
days,  and  by  no  means  force  him.  To  please  the  mother,  let's 
order  a  little  chalk  mixture  every  three  or  four  hours. 

CLINIC  n.— BABY  5 

Age. — Six  months  three  weeks. 

Mother  says  the  baby  still  has  coryza,  a  bad  cough,  and  won't 
eat.  The  diarrhea  is  better,  but  yesterday  he  had  four  rather 
loose  movements. 

Weight. — Thirteen  pounds  one  ounce.     No  gain. 

Temperature. — 100.2°  F. 

Examination. — Coryza  and  bronchitis. 

*  "Studies  on  Parenteral  Infections,"  Archives  of  Pediatrics,  1916,  671. 


328  INFANT  FEEDING    (CHICAGO  METHODS) 

Discussion. — Gentlemen,  the  child  has  not  gained  during 
this  past  week.  Probably  he  hasn't  eaten  as  much  as  usual. 
The  persistency  of  the  bronchitis,  with  the  associated  fermenta- 
tion in  the  intestine,  however,  makes  us  hesitate  about  urging 
any  forced  feedings,  particularly  as  mother  says  baby  is  not 
hungry.     Let's  wait  another  week  until  he  gets  over  this  cold. 

CLINIC  m.— BABY  5 

Baby  much  better.     Cough  improved.     Appetite  returned. 
Weight. — Thirteen  pounds  ten  ounces.    Gain  of  nine  ounces. 
Examination. — Negative. 

CLINIC  L— BABY  6 
Dr.  A.  F.  Fortune  (Greensboro) 

Age. — Seven  months. 

History. — Family  history  negative.  The  child  was  breast 
fed  up  to  one  month,  then  received  malted  milk  for  five  months, 
but  didn't  do  well;  was  hungry  and  had  diarrhea  all  the  time. 
Came  to  the  doctor  yesterday  for  advice.     He's  better  now. 

Temperature. — 97.8°  F. 

Weight. — Eleven  pounds  eight  ounces. 

Examination  shows  baby  only  fairly  nourished,  with  inelastic, 
mud-colored,  thin  skin  which  wrinkles  easily,  and  flaccid  muscu- 
lature. 

Discussion. — ^As  the  doctor  has  ruled  out  tuberculosis  and  is 
positive  there  is  no  trace  of  lues  in  the  family,  and  as  an  exami- 
nation has  ruled  out  anything  of  a  constitutional  nature,  the 
findings,  with  this  history  of  improper  feeding,  establish  the 
diagnosis  of  mild  decomposition  of  the  alimentary  type. 

Directions. — Just  to  contrast  different  methods  of  treatment, 
let's  order  a  simple  milk  mixture  and  omit  temporarily  the  soft 
diet.     Mother  give  the  baby — 

Milk 20  ounces 

Water 11  ounces 

Sugar 3  teaspoonfuls 

Boil  this,  divide  it  into  five  bottles  of  six  ounces  each,  feed  the 


CLINICS  329 

baby  regularly  once  every  four  hours,  and  be  sure  to  return 
next  week. 

Discussion. — Gentlemen,  personally  for  all  children  over  six 
months  of  age  I  prefer  a  soft  diet,  but  I'll  order  this  milk  mixture 
so  that  you  may  compare  the  result  here  with  those  of  Baby  1. 

CLINIC  v.— BABY  6 

Age. — Eight  months. 

Mother  says  she  didn't  bring  the  baby  back  before  because  he 
gained  so  well  for  a  few  weeks  she  thought  it  wasn't  necessary. 
For  the  last  few  days  his  bowels  moved  five  or  six  times  a  day, 
he  has  vomited,  and  looks  very  puny  again.  No  blood  in  the 
stools. 

Weight. — Ten  pounds,  showing  a  loss  of  one  and  one-half 
pounds  in  four  weeks. 

Temperature.— ^1 .2°  F. 

Examination. — Negative  as  to  causes  other  than  feeding. 

Discussion. — The  reason  for  this  loss  in  weight  easily  is  ex- 
plained. You  know  the  great  importance  of  carbohydrate. 
We  withdrew  sugar  for  just  a  few  days,  intending  to  supplement 
it  with  cereals,  zwieback,  and  other  non-fermentable  carbo- 
hydrates. However,  mother  didn't  bring  baby  back,  and  now 
for  four  weeks,  due  to  lack  of  carbohydrate,  and  of  course  to 
other  food  elements,  too,  he  has  been  developing  a  severe  de- 
composition. 

The  onset  of  the  diarrhea  a  few  days  ago  shows  the  beginning 
intolerance  to  food,  and  he  now  is  in  worse  condition  than  when 
we  first  saw  him. 

Directions. — We'll  put  him  then  on  regulation  treatment  for 
decomposition.  We'll  reduce  the  concentration  of  the  milk  to 
about  half — 

Milk 15  ounces 

Water 15  ounces 

Five  bottles. 

We'll  add  non-fermentable  carbohydrate  to  the  mixture, 
approximately  four  teaspoonfuls  of  dextri-maltose,  and  to 
sweeten  a  little,  I  think  it  safe  to  add  one  or  two  teaspoonfuls  of 
sugar.     We'll  give  four  ounces  every  three  hours,  and  very  care- 


330  INFANT   FEEDING    (CHICAGO   METHODS) 

fully  start  zwieback  and  cereal  once  or  twice  a  day.  We  may 
also  offer  carbohydrate  in  the  form  of  a  httle  mashed  potato. 
Return  in  a  week. 

Question  by  Dr.  Woodson. — Did  I  understand  you  to  say 
mashed  potatoes  for  a  baby  of  seven  months  in  this  condition? 

Answer. — Yes,  if  very  thoroughly  cooked  and  mashed  and 
given  in  small  doses  this  is  a  convenient  way  of  giving  non- 
fermentable  carbohydrate. 

Discussion. — This  was  the  child  in  whom  we  treated  the 
condition  of  decomposition  by  an  ordinary  milk  mixture  instead 
of  a  soft  diet.  If  the  mother  had  returned,  as  she  should  have, 
the  result  would  certainly  not  have  been  so  unsatisfactory. 
Don't  think  that  one  will  accomplish  such  poor  results  by  the 
exclusive  use  of  mik  mixtures,  but  at  any  rate,  on  a  soft  diet, 
such  an  unfortunate  occurrence  could  not  have  happened,  for 
the  child's  demand  for  carbohydrate  would  have  been  covered 
by  the  cereals,  potatoes,  zwieback,  and  Graham  crackers. 

CLINIC  VI.— BABY  6 

Age. — Eight  months  one  week. 

Mother  says  the  child  is  much  improved;  he  is  eating  zwie- 
back and  cereal,  and  she  is  keeping  the  milk  formula  as  directed. 
Bowels  move  two  or  three  times  daily  and  are  almost  normal. 

Weight. — Eleven  pounds  four  ounces,  representing  a  gain  of 
one  pound  four  ounces  in  a  week. 

Temperature.— 9^.4°  F. 

Examination. — Child  better  and  brighter. 

Directions. — No  change  in  feeding  is  necessary. 


CLINIC  Vm.— BABY  6 

Age. — Eight  months  three  weeks. 
Mother  says  the  baby  is  doing  nicely. 

Weight. — Twelve  pounds,  showing  a  gain  of  twelve  ounces  in 
two  weeks. 

Temperature.— 9S.Q°  F. 
Examination. — Doing  nicely. 
Directions. — No  change. 


CLINICS  331 

CLINIC  I.— BABY  7 
Dr.  Thomas  Anderson  (Statesville) 

Age. — Eight  and  one-half  months. 

History  tells  us  he  is  a  premature,  weighing  three  pounds  at 
birth.  After  a  few  months  of  breast  feeding  mother  lost  her 
milk  and  gave — 

Milk 10  ounces 

Water 12  ounces 

Sugar ^. .  6  teasp)oonf uls 

Seven  bottles. 

He  is  hungry  and  suffers  frequently  from  diarrhea. 

Temperature. — 97.6°  F. 

Weight. — Six  pounds  twelve  ounces. 

Examination. — Having  ruled  out  tuberculosis  and  syphilis, 
examination  shows  nothing  more  than  an  extremely  rachitic, 
anemic,  undernourished  child  in  a  state  of  decomposition. 

Directions. — You  see  the  importance  of  a  careful  history. 
The  fact  that  he  is  decidedly  premature  makes  us  very  careful 
indeed,  particularly  as  he  is  also  in  a  state  of  decomposition. 
Let  us  wait  a  week  and  see  what  he  is  doing,  except  let's  use 
dextri-maltose  instead  of  sugar. 

CLINIC  n.— BABY  7 

Age. — Eight  months  three  weeks. 

Mother  says  the  baby  shows  no  change — that  he  still  frets 
considerably.     Bowels  move  three  times  a  day. 

Weight. — Six  pounds  twelve  ounces,  showing  no  gain. 

Temperature. — 97.6°  F. 

Examination. — No  change. 

Directions. — Increase  very  carefully  to — 

Milk 14  ounces 

Water 12  ounces 

Dextri-maltose 6  teaspoonfuls 

Seven  bottles. 

Discussion. — In  feeding  prematures  there  are  a  few  points  to 
be  considered:  First,  remember  that  in  every  case  you  should 
suspect  lues — not  that  you  will  find  it,  but  you  always  must 
consider  it. 


332  INFANT   FEEDING    (CHICAGO   METHODS) 

Next,  if  you  are  working  with  calories,  prematures  need  more 
than  do  normal  babies.  Dr.  Julius  H.  Hess,  of  our  city,  made  a 
nice  study  recently,  showing  this  higher  requirement.  This  is 
easily  understood,  for  the  premature  must  gain  not  only  as  does 
a  normal  baby,  but  must  make  up  back  losses. 

An  interesting  point  in  feeding  is  brought  out  by  Langstein. 
Up  to  this  time  the  mortaUty  of  his  prematures  was  very  high. 
In  many  instances,  when  put  to  the  breast,  due  to  their  great 
weakness,  they  tired  before  getting  sufficient  food,  and  from  the 
resulting  inanition,  developed  decomposition  and  death.  Lang- 
stein found  that,  by  forcing  feedings  either  with  a  medicine- 
dropper  or  a  stomach-tube,  by  getting  more  food  into  them, 
the  mortality  was  greatly  reduced.  Gentlemen,  if  your  pre- 
mature on  the  breast  isn't  gaining,  don't  waste  time.  Put  him 
to  the  breast  more  frequently.  If  he  still  doesn't  gain,  force 
more  food  into  him,  either  with  a  medicine-dropper  or,  if  that 
fails,  with  a  stomach-tube.  In  this  baby  we  won't  waste  any 
time,  but  as  his  curve  shows  no  gain,  we  increase  at  once. 

A  valuable  point  is  the  following :  Often  the  amount  of  breast 
milk  necessary,  overloads  the  stomach,  causes  vomiting,  and 
defeats  our  purpose.  This  we  readily  may  obviate  by  offering 
small  quantities  of  buttermilk  mixture — a  mixture  of  boiled 
buttermilk  with  5  percent  dextri-maltose.  This  is  food  of  high 
concentration,  and  is  indicated  particularly  in  prematures,  who 
seem  to  need  especially  protein  and  salts.  However,  remember 
that  this  combination  is  one  of  concentrated  whey  with  carbo- 
hydrate, and  is  likely  to  induce  intestinal  fermentation  and 
nutritional  disturbances;  so  under  no  circumstances  offer  more 
than  one-third  or  one-half  of  the  total  amount  of  breast  milk 
given. 

Clinical  observation  has  taught  that  prematures  and  many 
twins  develop,  almost  invariably,  during  the  third  or  fourth 
month,  severe  anemias  and  bad  rickets.  It  was  Czerny  who 
first  offered  an  explanation.  Just  consider  for  a  moment  the 
composition  of  breast  milk.  In  one  quart  there  is  eir  grain  of 
iron  and  little  over  7  grains  of  calcium.  There  is  insufficient 
iron,  barely  enough  calcium,  to  cover  the  needs  of  the  child. 
Czerny  suggested  that  during  the  last  three  months  of  intra- 
uterine life  storage-warehouses  of  iron  develop  in  the  body. 


CLINICS  333 

The  main  one  seems  to  be  in  the  liver.  During  the  first  months 
of  Ufe,  while  baby  is  on  the  breast,  he  doesn't  live  on  the  iron  of 
breast  milk  but  upon  that  in  the  body.  In  a  like  manner,  Czerny 
suggested  calcium  warehouses,  although  the  latter  are  not  quite 
so  well  established  as  the  former.  Now  you  see,  gentlemen,  why 
prematures  develop  anemia  and  rickets.  They  have  come  into 
the  world  before  these  deposits  have  been  developed,  and  the 
supply  of  iron  and  calcium  in  breast  milk  is  insufficient  for  their 
needs.  In  a  like  way,  twins  suffer  because  they  have  to  share 
their  supply  with  each  other. 

It  is  a  good  idea,  as  a  prophylactic,  in  all  cases  of  twins  and 
prematures,  to  add,  after  the  first  few  months,  a  little  calcium, 
some  cod-liver  oil,  and  often  some  iron.  If  you  practise  these 
methods  of  prophylaxis,  you  will  be  gratified  with  your  success. 
Severe  anemias  rarely  develop,  and  rickets  appears  only  in  its 
milder  forms. 

The  same  conditions  exactly  develop  in  those  children  fed  too 
long  on  the  breast.  Don't  think  for  a  minute  that  breast  milk 
is  the  ideal  food  for  a  baby  over  six  to  nine  months  of  age.  There 
is  nothing  wrong  with  breast  milk,  but  it  doesn't  supply  suffi- 
ciently, the  ingredients  necessary.  Of  course,  some  children  cover 
their  demands  by  taking  a  larger  quantity  of  milk  from  the 
breast,  particularly  if  the  mother  has  an  abundant  supply,  but 
you'll  find  that  most  normal  children,  if  kept  exclusively  on  the 
breast  after  nine  months  of  age,  will  develop  anemias  and  rickets, 
just  as  do  prematures  and  twins. 

From  these  studies  of  physiology,  you  will  understand  why  I 
have  always  insisted  upon  a  mixed  diet  for  every  child  of  six 
months  of  age.  The  purpose  is  to  provide  for  these  known  defi- 
ciencies, and  also  for  some  of  those,  perhaps,  whose  existence, 
though  now  unknown,  may  be  revealed  in  future  observation 
and  experiment. 

In  regard  to  calcium,  how  we  give  it  is  unimportant,  provided 
we  give  it  in  the  form  the  baby  Hkes.  I  should  suggest  a  mixture 
of 

Calcium  lactate 1 H  drams 

Syrup  of  orange,  to  make 4  ounces 

Two  teaspoonfuls  three  times  a  day. 

This  gives  about  six  grains  of  calcium  three  times  daily. 


334  INFANT  FEEDING    (CHICAGO   METHODS) 

The  addition  of  cod-liver  oil  can  be  as  follows: 

Ol.  morrhuae Sviij 

Ol.  phosph 3i 

SiG. — Teaspoonful  thrice  daily  after  meals. 

As  each  teaspoonful  contains  one  drop  of  oil  of  phosphorus, 
and  as  one  drop  of  oil  of  phosphorus  contains  xirr  grain  of 
phosphorus,  a  teaspoonful  of  this  mixture  contains  tw  grain  of 
phosphorus.  You  also  may  use  mixtures  of  cod-liver  oil  and  malt. 

These  mixtures  aren't  delicious,  but  if  you  persist,  children 
take  them  well.  As  they  sometimes  impair  the  appetite,  it  is  a 
good  idea  to  give  them  after  the  feeding.  On  the  other  hand,  if 
baby  vomits,  give  before  the  feeding.  Then,  if  the  baby  vomits, 
it  makes  no  difference.  Don't  pay  any  attention  to  the  vomit- 
ing, but  keep  up  the  treatment,  and  the  majority  of  children 
learn  to  take  it  readily.  In  some  cases  it  may  be  wise  to  start 
with  10  to  15  drops  and  slowly  increase  to  a  teaspoonful. 

CLINIC  m.— BABY  7 

Age. — Nine  months. 
Mother  says  child  is  still  hungry. 

Weight. — Seven  pounds,  showing  a  gain  of  four  ounces  dur- 
ing the  week. 

Temperature.— 9S°  F. 

Examination. — No  change.     Still  peevish. 

Directions. — 

Milk 18  ounces 

Water 10  ounces 

Dextri-maltose 8  teaspoonf uls 

.Seven  bottles. 

Continue  calcium  and  cod-liver  oil. 

CLINIC  VI.— BABY  7 

Age. — Nine  months  three  weeks. 
Mother  says  baby  is  much  better. 

Weight. — Eight  poimds  four  ounces,  showing  a  gain  of  one 
pound  four  ounces  in  three  weeks. 
Temperature.— 98.S°  F. 
Examination. — Child  better. 


CLINICS  335 

CLINIC  Vn.— BABY  7 

Weight. — Eight  pounds  twelve  ounces,  showing  a  gain  of  8 
ounces  during  the  week. 
Better. 

CLINIC  Vm.— BABY  7 

Weight. — Nine  pounds,  showing  a  gain  of  4  ounces  during  the 
week. 

Directions. — Give  a  httle  cereal  and  continue  calcium  and 
cod-liver  oil.     Slowly  start  a  soft  diet. 

Examination. — A  fine  baby.  No  signs  of  rickets  other  than 
a  shght  rosary. 

CLINIC  I.— BABY  8 
Dr.  S.  F.  Pfohl  (Winston-Salem) 

Age. — Four  and  one-half  months. 

History. — Family  and  past  history  are  negative,  except  that 
during  the  first  two  days  of  life  the  child  had  fourteen  hemor- 
rhages from  the  bowels.  These  stopped  upon  injections  of 
horse-serum.  Since  then  he  has  been  on  the  breast,  but  is 
gaining  slowly  and  is  very  pale.  Mother  now  has  no  milk  and 
is  giving — 

Milk 10  ounces 

Water 9  ounces 

Sugar 5  teaspoonf  ula 

Six  bottles. 

He  is  not  gaining  on  this  and  is  very  constipated. 

Temperature. — 97.6°  F. 

Weight. — Seven  pounds  three  ounces. 

Examination. — Rachitic  baby  of  the  decomposition  type,  with 
extreme  pallor. 

Discussion. — Gentlemen,  here  is  an  example  illustrating  in 
another  way  the  points  of  the  previous  case.  This  child  suf- 
fered at  birth  a  great  loss  of  iron  from  his  system,  and  the  feed- 
ings since  are  insufficient  to  make  up  this  great  loss. 

Directions. — We'll  increase  his  food  slightly: 

Milk 14  ounces 

Water 8  ounces 

Sugar 6  teaspoonfuls 

Six  bottles. 


336  INFANT   FEEDING    (CHICAGO   METHODS) 

We  also  will  offer  iron,  as  we  would  to  prematures  and  twins; 
here,  however,  not  as  a  prophylactic,  but  as  actual  treatment. 
The  most  convenient  form  is  the  saccharated  carbonate.  The 
ordinary  dose  is  three  to  four  grains,  but  for  practical  purposes 
it  is  sufficient  to  tell  the  mother  to  take  as  much  as  she  can  put 
on  the  end  of  an  ordinary  knife.  Give  this  to  the  baby  in  a 
teaspoonful  of  water  about  three  times  a  day.  Children  take 
it  well. 

CLINIC  n.— BABY  8 

Age. — ^Four  months  three  weeks. 

Mother  says  the  baby  is  much  better,  but  she  is  dissati^ed 
with  the  stools,  which  are  green,  watery,  and  contain  curds. 
Three  movements  a  day.  The  baby  himself  is  happier  and 
more  contented. 

Weight. — Seven  pounds  ten  ounces,  representing  a  gain  of 
seven  ounces  in  a  week. 

Temperature. — 98°  F. 

Examination. — Color  hasn't  changed  much. 

Directions. — As  we  are  more  interested  in  the  baby  than  in  the 
stools,  and  as  he  has  gained  more  than  we  anticipated,  we'll 
let  him  alone.  Forget  about  the  stools,  and  feed  him  just  as 
you  are  doing.     Return  in  a  week.     Continue  the  iron. 

CLINIC  m.— BABY  8 

Age. — ^Five  months. 

Mother  says  baby  is  better  and  brighter  in  every  way.  Stools 
are  normal. 

Weight. — Seven  pounds  fourteen  ounces.  Gain  of  four  ounces 
in  a  week. 

Temperature.— 98.2°  F. 

Examination. — No  change  except  a  bit  of  color  in  baby's 
cheeks. 

CLINIC  IV.— BABY  8 

Baby  improving  nicely.  Is  now  hungry  again  and  consti- 
pated. 

Weight. — Eight  pounds  one  ounce.  Gain,  three  ounces  in  the 
week.     This  is  not  sufficient  and  is  an  indication  for  more  food. 

Temperature. — 98°  F. 


CLINICS  337 

Examination. — Child  looks  fresher.     More  color  to  cheeks. 
Directions. — Continue  iron.     Increase  diet  to — 

Milk 16  ounces 

Water 9  ounces 

Sugar 7  teaspoonf  uls 

Six  bottles. 

CLINIC  I.— BABY  9 
Dr.  R.  E.  L.  Flippen  (Pilot  Mountain) 

Age. — Four  months. 

History. — Family  and  past  history  negative.  As  regards 
feeding:  He  received  condensed  milk  during  the  first  two  and 
one-half  months.  The  mother  couldn't  nurse  him,  and  at  that 
time  he  suffered  severe  dysentery,  with  sixteen  stools  a  day. 
These  showed  blood  infrequently.  For  the  most  part  they 
were  thin  and  watery,  with  mucus — probably  not  of  the  infec- 
tious type. 

From  then  until  the  present  the  child  got  Mellin's  Food  and 
barley  water.  He  doesn't  seem  doing  well,  cries  incessantly, 
and  apparently  the  food  is  not  agreeing  with  him.  He  is  suffer- 
ing from  no  cough,  fever,  or  other  disturbance.  The  only 
symptoms  seem  to  be  indigestion,  occasional  vomiting,  and 
frequent  attacks  of  diarrhea.  At  present  stools  are  about  four 
to  six  a  day — ^green,  watery,  with  mucus  and  curds. 

Temperature. — 98°  F. 

Weight. — Ten  pounds  nine  ounces. 

Examination. — Almost  the  first  glance  tells  us  that  he  belongs 
to  the  disturbances  of  nutrition.  You  notice  the  flabby,  in- 
elastic skin,  its  peculiar  muddy  color  particularly  about  the  .eyes 
and  cheeks,  and  the  bluish  rings  around  the  eyes.  The  sore 
buttocks  suggest  acid  stools.  Notice  how  he. puts  his  fist  in  his 
mouth.  He  doesn't  cry,  but  he  doesn't  look  happy.  Notice 
the  tenseness  and  rigidity  of  the  muscles.  This  occurs  often  in 
children  on  one-sided  carbohydrate  diets.  Of  course,  we  must 
not  jump  to  such  a  conclusion  without  ruling  out  diseases,  as 
meningitis  or  birth  paralyses,  but  examination,  excepting  for  a 
few  cervical  glands  of  pea  size,  is  absolutely  negative. 

Diagnosis. — We  have  here  a  mild  decomposition.  This  child, 
however,  is  also  in  a  condition  of  dyspepsia,  and  I  am  glad  he 
22 


338  INFANT   FEEDING    (CHICAGO   METHODS) 

came  today,  because  he  illustrates  nicely  the  subject  of  the 
lecture. 

Treatment. — Mother,  in  order  to  give  his  stomach  and  in- 
testines a  rest,  for  the  remainder  of  the  day  give  him  absolutely 
nothing  but  a  little  weak  tea.  You  may  sweeten  it  with  a 
pinch  of  sugar,  but  just  enough  to  sweeten  it  slightly. 

Question  by  Mother. — How  shall  I  give  it? 

Answer. — At  his  regular  feeding  hours,  6,  10,  2,  6,  and  10 
o'clock.  Give  him  as  much  as  he  wants  at  these  times,  and 
nothing  whatsoever  between  meals. 

Question  by  Mother. — What  kind  of  tea  shall  I  give? 

Answer. — Any  tea  at  all  that  you  use  at  home,  green  or  black, 
provided  you  make  it  weak.  Tomorrow  start  with  a  mixture 
of  one-third  milk: 

Milk 10  ounces 

Water 20  ounces 

Sugar 3  teaspoonf uls 

Five  feedings. 

Keep  him  on  this  for  two  days,  and  then  push  him  up  gradu- 
ally by  the  end  of  the  week  to — 

Milk 15  ounces 

Water 16  ounces 

Sugar 5  teaspoonf  uls 

Five  feedings. 

The  doctor  will  see  you  during  the  week. 

To  Doctor. — You  see,  we  started  the  baby  on  one-third  milk, 
and  ordered  the  mother  to  increase  it  in  a  few  days.  I  think 
it  would  be  a  good  idea  to  run  in  and  judge  how  the  baby  is 
doing  before  the  mother  makes  this  increase.  Let  your  index, 
to  the  best  of  your  ability,  be  the  weight  curve,  and  if  the  baby 
ceases  losing  weight  and  seems  better,  make  the  increase.  On 
the  other  hand,  if  he  should  lose  rapidly  and  the  diarrhea  con- 
tinue, better  wait  for  a  day  or  two.  If  you  have  no  access  to 
scales,  perhaps  it  would  be  wiser  to  go  by  the  number  of  stools 
in  this  case,  and  not  increase  unless  the  stools  have  decreased 
to  approximately  three  or  four  a  day.  In  all  our  treatment  we 
are  influenced  far  more  by  the  number  of  the  stools  than  by 
the  appearance  of  the  individual  stool. 


CLINICS  339 


CLINIC  n.— BABY  9 

Age. — Four  months  one  week. 

Mother  says  the  baby  is  better  and  happier  in  every  way. 
He  is  very,  very  hungry  and  not  satisfied  with  the  bottle — he 
wants  more — he  can't  wait  four  hours;  indeed,  she  gives  him  a 
httle  in  between.     The  stools  have  diminished  to  three  daily. 

Weight. — Eleven  pounds  one  ounce,  showing  a  gain  of  eight 
ounces. 

Temperature. — 98°  F. 

Examination. — Child  looks  fresher. 

Discussion. — Gentlemen,  we  are  far  happier  with  the  gain  in 
weight  than  we  are  with  the  diminished  stools,  although,  of 
course,  both  are  very  gratifying  to  us.  We  now  have  the  child 
in  such  condition  that  his  general  nutrition  is  improving. 

Directions. — I  think,  in  such  a  condition,  we  can  pay  heed  to 
the  appeal  of  the  mother  and  the  baby  and  order  an  increase, 
as  his  present  diet  is,  of  course,  insufficient.  We  '11  do  this  very 
carefully;  but  as  the  baby  is  gaining  and  happier  in  every  way, 
I  think  we're  justified.     Let's  increase  to — 

Milk 18  ounces 

Water 13  ounces 

Sugar 6  teaspoonf  uls 

Five  bottles. 

I  risk  this,  gentlemen,  because  the  baby  is  over  four  months 
of  age,  and  the  older  the  child,  of  course,  the  less  susceptible, 
but  you  notice  we  keep  the  concentration  of  milk  still  not  much 
over  one-half. 

CLINIC  m.— BABY  9 

Age. — Four  months  two  weeks. 

Mother  says  the  baby  is  much  improved.  The  stools  vary 
from  three  to  four  a  day.     He  is  hungry. 

Weight. — Eleven  pounds  four  ounces,  showing  a  gain  of  three 
ounces  in  one  week. 

Temperature.— ^^.2°  F. 

Examination. — As  before. 

Directions. — As  he  cries  considerably;  as  the  scales  show  in- 


340  INFANT  FEEDING    (CHICAGO   METHODS) 

sufficient  gain  and  the  intestinal  tract  is  in  better  condition, 
we  increase  to — 

Milk 20  ounces 

Water 11  ounces 

Sugar 6  teaspoonf uls 

Dextri-maltose 3  teaspoonfuls 

Five  bottles. 

We  add  dextri-maltose,  as  it  is  not  so  sweet  as  cane-sugar  and 
because  it  is  less  fermentable. 


CLmiC  v.— BABY  9 

Age. — Five  months. 

Mother  says  the  baby  is  doing  nicely,  but  for  the  last  week  he 
has  been  crjdng  considerably.  He  doesn't  vomit;  has  no  coUc; 
but  just  cries  all  the  time.  He  has  no  cough,  fever,  diarrhea. 
He  stops  crying  if  she  picks  him  up. 

Weight. — Twelve  pounds  one  ounce,  showing  a  gain  of  thir- 
teen ounces  in  the  last  two  weeks. 

Temperature.— 98.S°  F. 

Examination. — As  regards  temperature,  foci  of  infection, 
otitis,  pharyngitis,  and  urinalysis,  negative. 

Discussion. — Gentlemen,  we  have  here  a  baby  who  seems  to 
cry  all  the  time.  Organically  there  is  nothing  wrong.  Can  it 
be  the  cry  of  hunger?  No,  for  the  child  has  gained  thirteen 
ounces  in  two  weeks.  Can  it  be  the  cry  of  indigestion  or  over- 
feeding? No,  for  there  has  been  no  vomiting  and  the  stools 
have  been  normal.  The  crying  is  not  related  to  meals.  We 
are  tempted  to  believe  the  following:  He  is  an  only  child.  Ex- 
perience has  taught  that  the  mother  of  an  only  child  usually 
is  an  exceedingly  nervous  individual.  She  fusses  continually, 
carries  him  more  than  he  should  be  carried,  and  often  excites 
him.     Is  that  true,  mother? 

Mrs.  Jones  (nurse)  states :  I  guess  we'll  have  to  admit  that — 
the  mother  is  really  very  anxious,  and  certainly  the  baby  has 
stopped  crying  whenever  she  picks  him  up. 

Discussion. — Gentlemen,  listen  to  that  crying.  It  is  not  that 
of  pain;  it  is  characteristically  that  of  temper.  See  the  value 
of  the  weight  curve!    It  is  a  greater  guide  to  us  even  than  baby's 


CLINICS  341 

disposition,  though  of  course  the  latter  is  of  value  also.  If  we 
were  guided  in  our  feeding  mainly  by  the  child's  temperament, 
we  should  have  changed  the  diet  in  this  case.  Mother,  pick 
up  the  baby  and  show  us  how  to  cure  him. 

Treatment. — Mother  instructed  not  to  worry  about  the  baby's 
crying;  told  that  the  cry  is  one  of  temper,  and  urged  to  let  him 
cry  to  his  heart's  content  for  a  few  days. 

CLINIC  Vn.— BABY  9 

Age. — Five  months  two  weeks. 

Mother  says  the  baby  is  better.  He  cries  much  less,  but  she 
finds  it  difficult  to  restrain  herself  from  picking  him  up. 

Weight. — Twelve  pounds  fifteen  ounces,  showing  a  gain  of 
fourteen  ounces  in  two  weeks. 

Temperature.— 9S.8°  F. 

Examination. — Negative. 

Directions. — No  change. 

CLINIC  I.— BABY  10 
Dr.  F.  Raymond  Taylor  (High  Point) 

Age. — Four  months. 

History. — Negative,  other  than  that  he  is  a  condensed  milk 
baby;  but  since  taken  to  Dr.  Taylor  last  week  he  has  received 
half  milk  and  half  water,  with  3  percent  dextri-maltose,  a  total 
of  24  ounces  a  day.  Previously  he  had  considerable  diarrhea, 
but  now  his  stools  seem  normal.  He's  much  better,  and  the 
mother  says  there  is  nothing  acute  the  matter  with  him — simply 
he  isn't  thriving. 

Temperature.— 97 .Q°  F. 

Weight. — Nine  pounds. 

Examination. — A  pale,  flabby  child.  Notice  the  emaciation. 
Peristalsis  can  be  seen  through  the  abdominal  wall.  See  how 
he  puts  his  fingers  into  his  mouth !  However,  we  have  one  good 
sign  here.  Although  he's  a  puny  little  fellow,  he  smiles.  Here 
again,  as  long  as  we  have  ruled  out  tuberculosis,  syphilis,  nephri- 
tis, and  cystitis,  and  as  physical  examination  is  absolutely  nega- 
tive, particularly  as  the  history  is  one  of  improper  feeding,  this 
child  belongs  to  the  group  described  as  decomposition. 


342  INFANT   FEEDING    (CHICAGO   METHODS) 

Question. — Mother,  is  he  hungry? 

Answer. — Yes,  he  certamly  would  take  more. 

Directions. — Well,  let  us  give  him  a  little  larger  quantity. 
Remember,  though,  it  is  wiser  to  offer  a  mixture  not  so  concen- 
trated as  for  a  normal  child.  Understand,  gentlemen,  for  such 
children  the  ideal  mixture  is  albumin  milk,  but  as  we  can't 
obtain  it,  we  have  to  use  an  ordinary  milk  mixture.  This  is 
much  less  efl&cient.    Let  us  order: 

Milk 15  ounces 

Water 16  ounces 

Dextri-maltose 8  teaspoonfuls 

Seven  bottles. 

CLINIC  n.— BABY  10 

Age. — Four  months  one  week.     (Does  not  return  to  Clinic.) 

The  nurse  says  the  baby  is  gaining  satisfactorily  according  to 
an  outside  scales,  and  his  stools  are  normal,  but  he  seems  hungry, 
and  asks  if  she  may  increase  the  diet. 

Weight. — Not  obtained. 

Temperature. — Not  obtained. 

Discussion. — (3€ntlemen,  whenever  a  baby  is  gaining  it  is 
unwise  to  increase,  especially  in  these  cases  of  marked  decom- 
position, if  you  cannot  see  the  baby  personally. 

Directions. — I  don't  beheve  I'd  make  any  change,  except 
possibly  a  sHght  increase  in  carbohydrate.  As  the  stools  are 
normal,  we  might  give  nine  teaspoonfuls  of  dextri-maltose  in- 
stead of  eight.  But  let  us  keep  the  concentration  of  the  milk 
unchanged.  As  he's  better,  we  might  ease  the  mother's  work 
by  ordering  five  feedings,  but  under  no  circumstances  change  the 
total  quantity  in  twenty-four  hours.  This  means  the  baby  will 
get  jfive  feedings  of  approximately  six  ounces  each. 

CLINIC  IV.— BABY  10 

Age. — Four  months  three  weeks. 

Mother  says  the  baby  is  very  sick.  He's  had  "  running  off "  of 
the  bowels,  seven  or  eight  movements  a  day,  and  has  been  vomit- 
ing a  lot.  She  is  sure  he  lost  weight.  His  food  for  the  past 
three  days  is  not  agreeing  with  him  at  all,  and  she  wishes  some- 
thing else. 


CLINICS  343 

Weight. — Eight  pounds  fourteen  ounces,  showing  a  consider- 
able loss,  for  the  child  weighed  nine  pounds  three  weeks  ago,  and 
had  been  gaining  considerably. 

Temperature. — 97°  F. 

Examination. — One  glance  shows  a  severe  nutritional  dis- 
turbance. The  skin,  which  three  weeks  ago  showed  returning 
elasticity,  fulness,  and  color,  again  is  inelastic  and  wrinkly. 
The  child  has  shrunken  in  every  way.  There  are  circles  under 
the  eyes.  The  smile  is  no  longer  present.  He  appears  anxious 
and  miserable.  The  cheeks  are  sunken,  and  generalized  rigidity 
is  marked.  There  is  no  coryza,  no  bronchitis,  no  tenderness 
over  the  ears,  no  redness  in  the  throat.  There  is  no  evidence 
of  parenteral  infection.  Here  we  have  a  decomposition  baby 
in  the  state  of  dyspepsia,  almost  verging  on  intoxication. 

Discussion. — Mother  says  the  food  is  not  agreeing  with  him. 
This  statement  I  am  not  prepared  to  admit,  for  a  food  upon 
which  a  child  is  thriving  will  not  all  of  a  sudden  become  in- 
jurious without  the  introduction  of  some  other  factor.  Here 
our  scales  are  a  check,  and  they  told  us  definitely  that  up  to  a 
few  days  ago  baby  had  been  gaining.  We  must  seek  some  other 
factor,  because  the  very  slight  change  in  the  diet  we  made  two 
weeks  ago  would  not  have  had  such  a  marked  effect  and  cer- 
tainly not  ten  or  eleven  days  after  it  had  been  ordered.  Indeed, 
we  ordered  a  slight  change  only,  feeling  we  wouldn't  be  justified 
in  anything  more  radical  without  seeing  the  baby. 

Question. — Mother,  has  he  coughed  or  sneezed  or  had  a  cold, 
or  has  he  been  putting  his  hands  to  his  ears  during  the  last  week 
before  his  trouble  started? 

Answer. — No,  I  haven't  noticed  that.  He  coughed  once  or 
twice  and  he  cried  a  lot. 

Question. — Did  he  cry  before  or  after  the  trouble  started? 

Answer. — He  cried  after. 

Discussion. — Gentlemen,  we  are  strongly  tempted  to  lay  the 
blame  to  this  little  cough,  but  I  don't  think  we  are  justified. 
It  was  too  mild.  Still  I  don't  want  to  censure  the  milk  mixture. 
What  other  outside  factors  might  be  important? 

Question. — The  weather  hasn't  changed  much.  Are  you 
dressing  the  baby  any  differently  than  you  did? 


344  INFANT   FEEDING    (CHICAGO   METHODS) 

Answer. — No,  during  these  hot  days  he  wears  just  his  shirt 
and  diaper. 

Discussion. — Heat  retention,  then,  can't  be  a  factor.  Pos- 
sibly the  mother  has  misunderstood  instructions.  Let's  see 
if  she  is  following  the  technic  of  feeding  accurately. 

Question. — Mother,  tell  us  exactly  how  you  are  feeding  the 
baby. 

Answer. — Well,  I  did  just  as  you  told  me.  I  increased  the 
food,  and  gave  him  six  ounces  in  each  bottle  as  I  was  directed. 

That  is  just  what  we  ordered. 

Question. — How  often  did  you  give  it? 

Answer. — Every  three  hours. 

Question. — How  often? 

Answer. — Every  three  hours. 

Discussion. — Well,  there's  the  trouble.  You  remember, 
gentlemen,  last  week  we  changed  to  the  four-hour  schedule  so 
as  to  make  it  easier  for  the  mother.  We  increased  the  amount 
to  six  ounces  in  each  bottle,  but  we  did  not  increase  the  total 
quantity  in  twenty-four  hours.  Mother  has  been  feeding  six 
ounces  every  three  hours,  which  means  a  total  of  forty-two 
ounces  of  food,  and  we  ordered  only  thirty  ounces.  So  we  have 
a  severe  dyspepsia  developing  from  overfeeding  in  a  decomposi- 
tion baby.  There  is  nothing  wrong  with  the  food  itself.  The 
trouble  was  too  much  food.  Now  we  must  treat  a  decomposition 
baby  plus  a  case  of  severe  dyspepsia.  I  wish  we  had  albumin 
milk.  We  give  nothing  but  tea  until  tonight;  then  one-third 
milk,  as — 

Milk 10  ounces 

Water 20  ounces 

Dextri-maltose 4  teaspoonf  uls 

Divide  this  into  seven  bottles  of  four  ounces  each. 

Now,  mother,  don't  give  over  four  ounces  at  a  feeding. 

In  a  day  or  two  we  shall  increase  the  concentration,  so  that 
by  four  or  five  days  he'll  get — 

Milk 15  ounces 

Water 15  ounces 

Dextri-maltose 6  teaspoonfuls 

Seven  feedings. 


CLINICS  345 

Remember  this  means  four  ounces  every  three  hours  for  seven 
feedings  in  a  day. 

Question  hy  Mother. — In  a  day  do  you  mean  day  and  night? 
Answer. — Seven  feedings  in  twenty-four  hours. 


CLINIC  v.— BABY  10 

Age. — Five  months. 

Mother  is  dissatisfied;  she  says  the  baby  is  better,  but  still 
vomits.     Stools  are  three  or  four  daily. 

Weight. — Nine  pounds  one  ounce,  showing  a  gain  of  three 
ounces  in  the  week. 

Temperature. — 98°  F. 

Examination. — Absolutely  no  change. 

Discussion. — The  child  has  gained  three  ounces  this  week. 
The  bowel  movements  have  improved;  the  child  looks  better. 
The  fact  that  the  weight  curve  is  rising  proves  that  this  gastric 
disturbance  is  not  affecting  his  nutrition.  As  we  get  no  history 
of  parenteral  infection,  and  as  our  examination  is  negative,  we 
ask  again,  "  can  it  be  possible  that  the  mother  still  is  not  follow- 
ing directions?" 

Question. — Mother,  tell  us  exactly  how  you  are  feeding  the 
baby. 

Answer. — I  make  double  the  amount  you  told  me. 

Question. — How  much  did  we  tell  you? 

Answer.— Milk,  15  ounces;  water,  15  ounces;  dextri-maltose, 
6  teaspoonfuls,  in  seven  feedings  of  four  ounces. 

Question. — That's  right;  but  why  twice  the  amount? 

Answer. — Fve  got  two  babies  at  home,  and  so  it  is  easier. 

Question. — Has  this  child  been  satisfied  with  four  ounces? 

Answer. — No,  he  wants  more. 

Question. — Don't  you  sometimes  give  him  a  little  of  his 
brother's  bottle,  mother? 

Answer. — Well,  sometimes  I  do. 

Question. — How  much? 

Answer. — For  the  last  few  days  I  gave  him  five  ounces? 

Discussion. — Gentlemen,  here  you  have  the  same  trouble 
over  again.  Last  week  we  treated  this  dyspepsia  by  food  with- 
drawal, and  then,  as  the  child  was  in  a  state  of  decomposition, 


346  INFANT   FEEDING    (CHICAGO   METHODS) 

we  were  particularly  careful  about  increasing.  The  baby  evi- 
dently improved  on  this  treatment,  for  he  gained  weight.  Now, 
however,  mother  is  pushing  the  quantity  too  rapidly,  and  this 
vomiting  is  a  symptom  of  another  beginning  overfeeding  dys- 
pepsia. In  this  case  it  is  unnecessary  to  withdraw  food  entirely 
because  the  baby  is  gaining.  I  think  if  we  limit  the  amount  and 
lessen  it  just  sufficiently  to  stop  the  vomiting,  the  result  will  be 
satisfactory. 

So,  mother,  if  you  want  the  baby  to  get  well  you  simply  must 
follow  our  instructions.  We  told  you  to  give  seven  feedings  of 
four  ounces,  and  no  matter  how  much  he  cries,  under  no  circum- 
stances give  him  any  more. 

Come  next  week. 

CLINIC  VI.— BABY  10 

Age. — Five  months  one  week. 

Mother  says  the  child  still  vomits,  but  somewhat  less  than 
last  week.  For  three  days  he's  had  diarrhea,  with  seven  or 
eight  watery  stools  a  day,  cries,  and  has  colic. 

Weight. — Nine  pounds,  showing  a  loss  of  one  ounce  in  the 
week. 

Temperature. — 99.4°  F. 

Examination. — Coryza. 

Discussion. — The  weight  curve  has  remained  almost  hori- 
zontal. The  stools  show  intestinal  fermentation.  So  here  we 
have  a  mild  dyspepsia. 

Question. — Mother,  how  long  has  the  baby  had  this  cold? 

Answer. — For  four  days.     His  nose  runs  all  the  time. 

Question. — Did  he  have  fever? 

Answer. — Yes,  I  think  he  had  a  Httle  fever. 

Question. — Is  he  better  now? 

Answer. — Yes,  he's  some  better. 

Discussion. — Gentlemen,  the  history  here  is  typical,  i.  e., 
a  decomposition  baby,  susceptible  as  he  is  to  every  external  in- 
fluence,— to  heat,  to  cold,  to  infections, — being  attacked  with  a 
slight  coryza.  One  day  later  he  reacts  with  diarrhea.  Such 
children  are  usually  very  sick  and  develop  severe  nutritional 
disturbances.  Here,  however,  our  weight  curve  makes  a  rela- 
tively good  prognosis.     The  very  slight  drop  shows  us  that  we 


CLINICS  347 

have  a  milder  disturbance,  only  a  dyspepsia,  and  not  a  severe 
form  of  that.  A  loss  of  one  ounce  in  a  few  days  is  of  no  grave 
significance. 

In  such  a  case,  two  courses  are  open.  If  we  could  see  the 
patient  every  day,  we  might  leave  the  milk  as  it  is,  or  even  in- 
crease it  shghtly,  and  at  the  same  time  withdraw  the  carbo- 
hydrate. This  would  give  us  high  protein  and  low  sugar  in  the 
intestinal  tract,  i.  e.,  factors  favoring  putrefaction  and  overcom- 
ing fermentation.  The  stools  would  become  constipated,  but 
the  child  would  react  with  a  considerable  loss  of  weight,  for  his 
tissues  would  feel  the  loss  of  the  carbohydrate.  The  same  result 
could  be  accomplished  with  the  use  of  buttermilk.  Then,  in  a 
day  or  two,  we'd  carefully  and  gradually  increase  the  sugar  to 
answer  the  tissue  requirements.  In  this  case,  however,  co- 
operation in  the  home  is  none  of  the  best.  We  may  not  see  the 
child  for  two  weeks.  Total  withdrawal  of  sugar  for  so  long 
would  probably  be  fatal;  and  again  an  injudicious  and  too  rapid 
increase,  with  some  fermentation  already  present  in  the  intes- 
tine, might  produce  an  intoxication.  I  think  the  alternative, 
though  apparently  somewhat  reckless,  will  be  safer  in  this  in- 
stance. Let's  take  into  consideration  that  we  may  not  see  this 
patient  for  some  days,  and  by  that  time  his  body  tissues  will 
need,  roughly,  three  percent  carbohydrate.  Let's  avoid  the 
possibility  of  any  error  in  the  home  and  so  order  that  much  at 
once.  From  this  amount,  however,  some  intestinal  fermenta- 
tion will  doubtless  arise,  and  so  we'll  try  to  provide  for  it  by 
ordering  putrefactive,  alkali-forming  reagents,  in  the  hope  of 
preventing  intestinal  damage.  Let  us  add  to  the  above  mix- 
ture, curds  of  one  pint  of  milk,  ground  very  thoroughly  through 
a  sieve;  in  addition,  a  few  teaspoonfuls  of  chalk  mixture  every 
few  hours,  and  I  believe  with  these  alkali-farming  agents  we 
may  increase  the  dextri-maltose  to  eight  teaspoonfuls,  thus 
attempting  to  give  the  body  tissues  the  carbohydrate  which 
they  need.  This  child  is  on  the  border  line,  however.  If  at  all 
possible,  the  doctor  should  see  him  every  few  days,  and  any 
evidence  of  a  further  drop  in  the  weight  curve  must  be  taken  as 
diagnostic  of  a  severer  dyspepsia,  and  typical  treatment  insti- 
tuted. 


348  INFANT  FEEDING    (CHICAGO  METHODS) 

CLINIC  Vn.— BABY  10 

Age. — Five  and  one-half  months. 

Mother  says  the  baby  is  much  improved.  Bowels  three  a 
day  and  still  loose,  but  he  seems  happy  and  much  more  content. 

Weight. — Nine  pounds  six  ounces,  showing  a  gain  of  six  ounces 
in  the  week. 

Temperature.— ^%.%°  F. 

Examination. — Looks  better. 

Directions. — ^No  change.    In  a  short  time  we'll  add  cereals. 

CLINIC  I.— BABY  II 
Dr.  J.  H.  Boyles  (Greensboro) 

Age. — ^Nineteen  lAonths. 

History. — Family  and  past  history  are  negative.  He's  been 
a  bottle  baby  since  two  months  of  age,  when  mother  lost  her 
milk.  Eagle  Brand  Condensed  Milk  was  given,  and  he  did  well 
for  some  time.  For  several  months  he  has  received  cow's  milk 
and  Graham  crackers,  potatoes,  and  soup.  For  some  time  he 
hasn't  been  doing  well.  He's  not  thriving;  has  frequent  in- 
digestion, and  is  very  puny.  The  mother  brought  him  three 
days  ago  because  of  severe  diarrhea,  with  15  to  20  watery  stools  a 
day.  There  was  no  blood  in  these  stools;  they  were  green, 
smelled  sour,  had  mucus  and  curds.  He  was  feverish,  seemed 
losing  weight,  vomited  considerably,  and  lay  in  a  stupor  most  of 
the  time.     He  was  very  sick. 

The  doctor  ruled  out  all  constitutional  disease,  parenteral 
infections,  tuberculosis,  and  syphilis.  Due  to  the  long  history 
of  improper  feeding  and  the  absence  of  blood  and  pus  in  the 
stools,  he  thought  definite  enteral  infection  unlikely.  Urinaly- 
sis was  negative,  and  he  made  the  diagnosis  of  alimentary  in- 
toxication complicating  a  condition  of  decomposition. 

Examination. — This  shows  a  child  in  a  miserable  state  of 
nutrition;  feeble,  peevish,  and  irritable.  The  skin  is  dry, 
wrinkled,  and  thin.  The  musculature  is  atrophied  and  rather 
rigid. 

Weight. — Sixteen  pounds  six  ounces. 

Temperature.— ^d,°  F. 


CLINICS  349 

Discussion. — Gentlemen,  although  diarrheas  in  children  of 
this  age  more  frequently  are  due  to  watermelon,  raw  sweet 
potatoes,  peanuts,  anything  the  child  may  lay  hands  on,  I  think 
the  diagnosis  in  this  instance  is  absolutely  correct.  Here  is 
a  history  of  decidedly  improper  feeding,  leading  to  decomposi- 
tion. The  primary  gain  on  condensed  milk  was  due,  of  course, 
to  the  sugar,  and  additional  feeding  of  Graham  crackers  and 
potatoes  furnished  still  more  carbohydrate.  There  has  been 
nothing  to  cover  the  child's  demand  for  protein,  for  salts,  pos- 
sibly for  fat.  Soups,  you  know,  have  no  food  value  other  than 
the  salts  they  contain. 

Question  by  Dr.  Beal. — Do  you  mean  to  say  that  soups  are  not 
nourishing? 

Answer. — The  ordinary  soup  which  we  offer  has  no  food  value; 
it  contains  simply  the  extractives  of  the  meat  and  leaves  the 
nourishing  part  behind.  We  feed  soups  to  supply  salts  and  to 
stimulate  the  appetite.  Children  like  them,  but  as  regards 
food  value,  they  are  unimportant. 

The  treatment  the  doctor  ordered  in  this  case  seems  absolutely 
perfect.     He  ordered  tea  for  twenty-four  hours.     Following 
this,  in  the  absence  of  albumin  milk,  and  because  a  child  of  this  • 
age,  and  even  as  sick  as  this  child  was,  unquestionably  can  tol- 
erate mixtures  of  cow's  milk,  the  doctor  ordered  a  mixture  of — 

Milk 15  ounces 

Water 15  ounces 

Dextri-maltose 6  teaspoonfuls 

On  this  treatment  the  child  is  better  and  happier  and  the 
diarrhea  has  improved  greatly. 

But,  gentlemen,  notice  how  he  keeps  his  hands  in  his  mouth; 
notice  his  puny  size,  his  thin,  flabby,  inelastic  skin.  Notice 
the  extreme  emaciation  and  rigidity  of  the  muscles  characteristic 
of  these  children  on  one-sided  carbohydrate  diets  (this  is  a 
typical  picture  of  Czerny's  starch  injury).  See  how  the  emacia- 
tion reveals  general  adenopathy,  as  in  tuberculosis!  The  rig- 
idity is  so  marked  as  to  make  us  think  of  Little's  disease.  These 
conditions  the  doctor  has  ruled  out,  and  the  weight  of  sixteen 
pounds  six  ounces  shows  the  miserable  state  of  nutrition,  and 
confirms  our  diagnosis  of  decomposition.     Here,  then,  we  have 


350  INFANT   FEEDING    (CHICAGO   METHODS) 

a  child  in  the  state  of  decomposition  who,  for  some  unknown 
reason,  developed  an  intoxication.  This  complication  has  been 
successfully  treated,  and  now  it  is  up  to  us  to  correct  the  state 
of  decomposition.  As  the  acute  disturbance  is  past,  let  us  give 
more  food. 

Directions. — We'll  keep  the  milk  in  dilute  concentration. 
Then  we  safely  can  give  more  carbohydrate  in  a  non-ferment- 
able form:  as  farina,  corn-starch,  arrow-root,  mush,  tapioca,  or 
Cream  of  Wheat.  We  may  give  a  little  mashed  potato.  I 
think  I'd  omit  oatmeal,  which  is  the  most  easily  fermentable 
cereal.  To  supply  salts  we  add  vegetable  purees.  To  supply 
protein,  and  in  this  case  also  to  keep  the  intestine  alkaline,  we 
add  pure  cottage  cheese,  or,  if  this  is  not  obtainable,  simply  the 
curds  of  milk.  In  a  baby  of  this  age  we  may  offer  finely  scraped 
meat,  such  as  a  chicken  or  lamb-chop.  We  may  add  custard 
and  zwieback.  I  think  I  would  feed  this  child  a  little  oftener 
than  the  nonnal  schedule,  namely,  every  three  hours, — seven 
feedings  in  twenty-four  hours, — and  remember,  increase  very 
slowly  and  caviiously.  By  no  means  give  him  everything  in 
one  day,  or  large  quantities  of  any  particular  food. 


CLINIC  n.— BABY  II 

Mother  says  the  child  is  much  better  and  happier.  His 
bowels  move  only  three  times  daily. 

Weight. — Seventeen  pounds  ten  ounces,  showing  a  gain  of 
one  pound  Jour  ounces  in  the  last  week. 

Temperature.— 9S.S°  F. 

Examination. — Looks  better,  brighter,  and  happier. 

Discussion. — Considering  the  above  gain  in  weight,  we  don't 
need  to  complain  about  the  therapeutic  results  in  this  case. 
The  child  now  is  eating  a  little  egg,  potato,  meat,  Graham  crack- 
ers, cereals,  and  milk,  and  seems  on  the  road  to  complete  re- 
covery. 

Directions. — Put  him  on  five  feedings. 

CLINIC  m.— BABY  11 
Mother  sends  in  report  that  baby  is  doing  nicely. 


CLINICS  351 

CLINIC  I.— BABY  12 
Dr.  H.  H.  Ogburn  (Greensboro) 

History. — Baby  is  three  months  old.  Family  and  past  his- 
tory negative.  The  baby  was  breast  fed  every  two  hours  since 
birth;  was  always  hungry,  always  fretful,  never  thriving;  he 
has  no  diarrhea,  but  is  puny  and  not  gaining. 

Temperature. — 97.4°  F. 

Weight. — Six  pounds  twelve  oimces. 

Examination. — This  shows  a  baby  of  the  typical  decomposi- 
tion type,  with  wrinkled  skin  and  cold  hands  and  feet. 

Diagnosis. — Although  the  appearance  is  that  of  decomposi- 
tion, we  have  learned  in  breast-fed  children  to  establish  the 
diagnosis  rather  of  inanition. 

Directions. — Having,  by  examination  and  tests,  ruled  out 
conditions  other  than  feeding,  we'll  treat  this  child  as  a  case  of 
inanition.  We'll  order  seven  nursings  in  twenty-four  hours,  the 
mother  to  allow  the  child  five  minutes  for  the  breast  and  then 
ten  minutes  for  the  bottle.  We  don't  know  how  much  this 
child  will  take  in  each  bottle,  but,  as  a  guess,  two  ounces.  This 
would  make  a  formula  of,  roughly — 

Milk 7  ounces 

Water 8  ounces 

Dextri-maltose 4  teaspoonfuls 

Seven  bottles. 

CLINIC  n.— BABY  12 

Age. — Three  months  one  week. 

Mother  says  the  child  is  better,  cries  less,  and  seems  happier. 
The  bowels  are  still  loose,  however — about  three  a  day. 

Weight. — Seven  pounds  four  ounces.  Gain  of  eight  ounces  in 
a  week. 

Temperature. — 97.8°  F. 

Examination. — Looks  better. 

Directions. — As  this  is  such  an  excellent  gain  in  this  puny 
child,  we'll  make  no  change. 


352  INFANT  FEEDING    (CHICAGO   METHODS) 

CLINIC  m.— BABY  12 

Age. — ^Three  months  two  weeks. 

Mother  says  the  baby  has  four  or  five  green,  watery  bowel 
movements  each  day.  He  doesn't  desire  much  food  and  has 
been  peevish  and  irritable. 

Weight. — Seven  pounds  four  ounces,  showing  no  gain  this 
week. 

Temperature.— 98.2°  F. 

Examination. — Negative.  There  is  no  parenteral  infection, 
and  the  child  doesn't  look  unhappy.  The  skin,  however,  isn't 
quite  as  fresh  looking  as  last  week,  and  there  are  suggestions  of 
rings  under  the  eyes. 

Discussion. — Gentlemen,  here  we  have  one  of  the  conditions 
in  which  perplexity  may  arise.  Are  these  watery,  green  bowel 
movements  of  significance  or  are  they  not?  The  weight  curve 
during  this  week  is  perfectly  straight.  Is  this  due  to  under- 
feeding, and  will  the  curve  and  stools  improve  upon  increase  of 
diet,  or  have  we  a  beginning  dyspepsia?  The  fact  that  he 
doesn't  desire  food  makes  us  cautious,  and  I  think  it  wiser  to 
hold  him  as  he  is.  The  fact  that  he  gained  well  last  week — 
eight  oimces — ^makes  us  in  no  particular  hurry,  and  if  this  be 
an  incipient  dyspepsia,  due  to  some  outside  factor, — possibly  a 
cystitis, — it  is  wiser  to  make  no  change  for  a  few  days  and  note 
the  reaction.     Meanwhile  we  await  urinalysis. 

Directions. — Mother  must  be  very  careful  to  feed  the  baby  just 
exactly  as  we  directed,  and  if  he  doesn't  want  all  his  food,  take 
the  bottle  from  him.     Don't  force  it! 

Bring  him  next  week. 

CLINIC  IV.— BABY  12 

Age. — ^Three  months  three  weeks. 

Mother  says  baby  is  much  better  but  seems  hungry.  Stools 
are  three  a  day  and  a  little  loose. 

Weight. — Seven  pounds  twelve  ounces,  showing  a  gain  of 
eight  ounces  in  the  last  week — really  in  two  weeks. 

Temperature. — 98°  F. 

Examination. — Child  looks  fresher.     Urine  reported  negative. 

Directions. — As  there  was  no  gain  in  the  previous  week,  and 


CLINICS  353 

as  he  seems  hungry  and  is  well  in  every  other  respect,  I  think  we 
are  justified  in  increasing  shghtly.  Let's  give,  in  addition  to 
the  breast. 

Milk 9  ounces 

Water 9  ounces 

Mellin's  Food  (as  the  mother  cannot  get 

dextri-maltose) 6  teaspoonfuls 

Seven  feedings. 

CLINIC  VI.— BABY  12 

Age. — Four  months  one  week. 
The  baby  is  happy  in  every  way  and  doing  nicely. 
Weight. — Eight  pounds  eight  ounces,  showing  a  gain  of  twelve 
ounces  in  two  weeks. 
Temperature.— ^^.^°  F. 

Examination. — Child  looks  bright,  happy,  and  contented. 
Directions. — No  change. 

CLINIC  I.— BABY  13 
Dr.  Ed.  King  (Statesville) 

Age. — ^Three  months. 

History. — Family  and  past  history  negative.  Twelve  other 
children  living  and  well.  The  baby  is  brought  for  vomiting, 
which  has  persisted  since  birth.  He  gets  the  breast  every  half- 
hour. 

Temperature. — 97.6"  F. 

Weight. — Nine  pounds. 

Examination. — A  fine,  healthy,  happy  baby. 

Discussion. — Persistent  vomiting  since  birth  makes  us  think 
of  pyloric  stenosis.  However,  if  such  were  the  case,  the  child's 
nutrition  would  be  markedly  affected.  One  look  rules  this  out. 
Vomiting  from  parenteral  infections  wouldn't  have  persisted  so 
long.  I'm  inclined  to  think  the  vomiting  is  due  to  the  improper 
technic  of  feedings  Perhaps  the  baby  is  underfed  and  mother 
puts  him  to  the  breast  every  half-hour  to  appease  him.  Of 
course,  continual  insult  to  the  stomach  makes  it  rebel. 

Directions. — Let  us  put  him  on  regular  nursings — twenty 
minutes  every  three  hours,  seven  feedings  in  twenty-four  hours — 

and  await  the  reaction. 
23 


354  INFANT  FEEDING    (CHICAGO   METHODS) 

CLINIC  n.— BABY  13 

Age. — Three  months  one  week. 

Mother  says  baby  has  ceased  vomiting,  but  is  very  consti- 
-pated,  fretful,  and  peevish. 

Weight. — Nine  pounds,  showing  no  gain  this  week. 

Temperature.— ^1  .^°  F. 

Examination. — No  change. 

Discussion. — Failure  to  gain,  with  no  vomiting,  no  diarrhea, 
and  with  constipation,  estabUshes  the  diagnosis  of  inanition. 

Directions. — Add  after  nursing: 

Milk 4  ounces 

Water '. 4  ounces 

Sugar 1  teaspoonf  ul 

Seven  bottles. 

CLINIC  m.— BABY  13 

Age. — Three  months  two  weeks. 
Baby  still  hungry — no  vomiting. 

Weight. — Nine  pounds  two  oimces,  showing  a  gain  of  two 
ounces  in  a  week. 
Directions. — Increase  diet  to — 

Milk 8  ounces 

Water 8  oiuices 

Sugar 3  teaspoonf  uls 

Seven  bottles. 

CLINIC  IV.— BABY  13 

Mother  sends  in  report  that  baby  is  doing  very  well  indeed 
and  seems  satisfied  and  contented. 

CLINIC  I.— BABY  14 
Dr.  A  E.  Bell  (Mooresville) 

Age. — Four  months. 

History. — Family  and  past  history  negative.  Baby  was 
breast  fed  for  one  month.  Mother  lost  her  milk  and  gave 
Mellin's  Food  with  cow's  milk.  Due  to  work  in  the  fields,  she 
has  never  given  him  proper  care,  leaving  him  to  grandmother, 


CLINICS  355 

who  doesn't  know  definitely  the  details  of  the  diet.  The  baby 
was  brought  to  Dr.  Bell  a  few  days  ago  on  account  of  severe 
diarrhea,  with  green,  watery,  sour-smelling  stools  containing 
mucus  and  curds.  Although  this  was  an  acute  attack,  the  child 
had  been  ailing  for  a  long  time.  He  is  better  now,  but  still  very 
weak. 

Weight. — Seven  pounds — less  than  when  he  was  born. 

Temperature. — 97°  F. 

Examination. — Physical  examination  other  than  extreme 
emaciation  and  weakness  is  negative.  Pirquet  and  urinalysis 
are  negative.  The  family  history  gives  no  reason  for  suspecting 
lues.     It  is  a  case  of  marked  decomposition. 

Directions. — In  such  an  extreme  case  we  prefer  infinitely 
breast  milk  or  albumin  milk.  An  ordinary  milk  mixture  is  far 
less  efficient.  Indeed,  I  doubt  whether  we  shall  accomplish 
much. 

Question. — Grandmother,  is  there  any  possibility  of  getting 
any  breast  milk  from  your  neighbors? 

Answer. — Yes,  Mrs.  Miller  just  had  a  new  baby  and  I  might 
get  a  little  from  her. 

Question. — Do  you  suppose  that  you  could  get  an  ounce  every 
two  hours? 

Answer. — I  think  so. 

Well,  then,  give  the  baby  an  ounce  at  6,  8,  10,  12,  2,  4,  6,  8, 
10  o'clock  and  once  or  twice  during  the  night.  Be  sure  to  warm 
the  milk  to  body  temperature  before  using,  and  feed  the  baby 
absolutely  regularly.  Don't  let  him  have  the  bottle  over  ten 
or  fifteen  minutes. 

Discussion. — Gentlemen,  this  child  is  sick  enough  to  need 
stimulation.  He  would* be  better  in  a  hospital.  Failing  such/ 
I  doubt  if  we'll  be  able  to  accomplish  much  in  the  home. 

We  know  that  proper  care  and  proper  nursing  are  equally 
as  important  as  certain  formulae.  I  haye  grave  fears,  as  you 
yourselves  probably  have, — after  noticing  grandmother's  hostile 
demeanor, — that  our  instructions  may  not  be  carried  out.  When- 
ever grandmother  looks  skeptical,  she  probably  intends  intro- 
ducing methods  of  her  own.  I  don't  beUeve  she  approved  of 
our  advice. 


356  INFANT  FEEDING    (CHICAGO   METHODS) 

CLINIC  n.— BABY  14 

Age. — Four  months  one  week. 

Grandmother  states  baby  is  better,  that  his  bowels  are  all 
right  and  his  appetite  good. 

Weight. — Seven  pomids  four  ounces,  showing  a  gain  of  four 
ounces  in  one  week. 

Temperature. — 98**  F. 

Examination. — No  change. 

Discussion. — Gentlemen,  you  remember  last  week  we  dis- 
cussed the  importance  of  care  in  the  home,  and  wondered  how 
frequently  our  directions  really  were  carried  out.  It  always  is 
interesting  to  learn  if  baby  really  has  improved  on  our  feedings, 
or  if  some  change  of  diet  which  the  nurse  never  admits  is  the 
fundamental  reason. 

Question. — Grandmother,  tell  us  just  exactly  what  you  gave 
the  baby. 

Answer. — Well,  doctor,  to  tell  the  truth,  I  was  able  to  get 
more  breast  milk  from  Mrs.  Miller  than  I  thought;  so  I  gave 
the  baby  four  ounces  instead  of  one. 

Question. — How  often  did  you  give  this,  grandmother? 

Answer. — Well,  I  tried  to  give  it  every  two  hours. 

Question. — You  don't  mean  that  you  gave  the  baby  four 
ounces  every  two  hours? 

Answer. — Perhaps  not  every  two  hours,  but  somewhere  near 
there. 

Qu£stion. — How  much  are  four  ounces? 

Answer. — I  didn't  measure  exactly,  but  Mrs.  Miller  said  she 
thought  there  were  four  ounces.     It  quarter  filled  my  glass. 

Discussion. — Gentlemen,  you  see  how  many  factors  come  into 
infant  feeding,  and  how  often  we  draw  absolutely  false  conclu- 
sions. In  this  instance  grandmother  says  she  offered  four  ounces, 
but  probably  the  baby  got  only  two.  One  fact  remains,  how- 
ever, the  baby  gained.  For  this  let  us  be  grateful;  so,  as  long  as 
he's  gaining,  we'll  be  justified  in  violating  dogmatic  routine  and 
continuing  the  amounts  which  grandmother  offers.  I  believe 
you  will  agree  with  me  that  in  this  case  it  is  impossible  to  demand 
an  exact  routine.  So,  grandmother,  as  long  as  the  baby  is  gain- 
ing, feed  him  as  you  are  doing,  but  try  to  be  regular,  and  measure 


CLINICS  357 

in  the  bottle  just  how  much  you  are  giving,  because  that  will 
help  us  greatly.  Try  to  feed  him  every  three  hours — 6,  9,  12, 
3,  6,  9  o'clock,  and  once  during  the  night,  and  tell  us  next  week 
how  many  ounces  he  takes,  as  you  measure  it  in  your  bottle. 


CLINIC  m.— BABY  14 

Age. — Four  months  two  weeks. 

Grandmother  says  the  baby  is  better. 

Weight. — Eight  pounds,  showing  a  gain  of  twelve  ounces  in 
the  week. 

Temperature.— ^^.4°  F. 

Examination. — Negative.  Notice  how  much  fresher  and  hap- 
pier he  looks,  and,  above  all  things,  notice  the  returning  elas- 
ticity to  the  skin  and  the  decided  change  in  color.  This  child 
is  doing  nicely. 

Question. — Grandmother,  how  are  you  feeding  the  baby? 

Answer. — I  am  feeding  him  just  exactly  as  you  told  me.  He 
seems  satisfied,  and  I  think  he's  much  better. 

He  gets  three  ounces  each  feeding. 


CLINIC  IV.— BABY  14 

Age. — Four  months  three  weeks. 

Grandmother  says  the  baby  is  doing  as  well  as  can  be  ex- 
pected. He  seems  more  cheerful,  but  she  can't  see  much  change 
in  his  weight.    Bowels  move  two  or  three  times  a  day. 

Weight. — Eight  pounds  four  ounces,  showing  a  gain  of  four 
ounces. 

Temperature. — 98.6°  F. 

Examination. — Baby  looks  better. 

Discussion. — Well,  gentlemen;  we  didn't  expect  a  very  notice- 
able change  in  such  a  tiny  baby,  but  the  scales  show  a  gain  of 
four  ounces.    This  isn't  bad. 

Question. — Grandmother,  what  have  you  been  giving  this 
week? 

Answer. — Well,  I  can  only  get  breast  milk  once  in  a  while, 
and  so  I  gave  five  ounces  whenever  I  could  get  it,  and  the  rest 
of  the  time  condensed  milk. 


358  INFANT   FEEDING    (CHICAGO   METHODS) 

Question. — How  much  breast  milk  did  you  give  him  in  twenty- 
four  hours? 

Answer. — I  don't  think  I  got  much  more  than  five  or  ten 
ounces. 

Question. — And  the  rest  of  the  feeding  was  condensed  milk, 
was  it? 

Answer. — Yes. 

Question. — How  much  in  each  bottle? 

Answer. — I  guess  about  five  ounces. 

Discussion. — You  see  how  careful  we  must  be  at  all  times. 
If  we  hadn't  learned  this,  we  should  have  attributed  this  gain 
to  breast  milk  and  would  have  been  pleased.  You  remember 
the  dangers  of  condensed  milk — how  a  child  gains  temporarily 
from  the  high  amount  of  carbohydrate,  but  that  this  gain  repre- 
sents water-logging  of  the  body  rather  than  true  gain  in  tissue 
substance.  So,  although  he  apparently  put  on  four  ounces,  we're 
not  satisfied.  If  we  must  use  artificial  food,  let  us  use  a  regular 
milk  mixture. 

Doctor,  will  you  explain  to  grandmother  during  the  week  the 
dangers  of  condensed  milk  feeding  and  let  us  figure  on  a  milk 
mixture  of — 

Milk 10  ounces 

Water 22  ounces 

Dextri-maltose 8  teaspoon! uls 

Seven  bottles. 

This  will  make  seven  feedings  in  twenty-four  hours,  of  four 
and  one-half  ounces  each — a  little  more  than  I  ordinarily  would 
order,  but  as  grandmother  has  been  giving  five  ounces  every 
three  hours,  I  think  we're  safe.  I'd  give  just  as  much  breast 
milk  as  possible  at  each  feeding.  Then  offer  a  bottle  for  ten 
minutes.  Let  him  take  as  much  as  he  wishes,  and  after  ten  or 
fifteen  minutes,  if  he  hasn't  finished,  take  it  away  and  make 
him  wait  until  the  next  feeding  time. 


CLINIC  v.— BABY  14 


Age. — Five  months. 

Grandmother  says  he  is  better,  but  hungry. 


CLINICS  359 

Weight. — Eight  pounds  eight  ounces,  showing  a  gain  of  four 
ounces  in  the  week. 

Temperature. — 98.4°  F. 

Examination. — No  marked  change. 

Discussion. — Gentlemen,  in  a  child  as  poorly  nourished  as 
this  one  we  mustn't  push  feedings  too  rapidly,  particularly 
where  we're  not  sure  of  the  nursing  cooperation  in  the  home. 
I  beheve  as  long  as  he's  gaining  we  should  leave  him  for  two  or 
three  days,  and  then,  if  he  seems  very  hungry,  we  might  in- 
crease to  perhaps — 

Milk 13  ounces 

Water 19  ounces 

Dextri-maltose 8  teaspoonfuls 

L  Seven  bottles. 

and  perhaps  toward  the  end  of  the  week — 

Milk 15  ounces 

Water 17  ounces 

Dextri-maltose 8  teaspoonfuls 

Seven  bottles. 


CLINIC  VI.— BABY  14 

Age. — Five  months  one  week. 

The  baby  had  a  diarrhea  this  week,  but  now  bowels  move 
only  once  or  twice  a  day.  Careful  questioning  shows  that  grand- 
mother overfed  the  baby,  and  of  herself  removed  food,  thus 
treating  successfully  the  resulting  dyspepsia. 

Weight. — Eight  pounds  four  ounces,  showing  loss  of  four 
ounces  during  the  week. 

Temperature. — 98°  F. 

Examination. — No  change. 

Directions. — Continue  to  feed  the  baby  as  ordered,  giving — 

Milk 15  ounces 

Water .17  ounces 

Mellin's  Food  (as  grandmother  can't  get  dextri- 
maltose)  1  ounce 

Seven  bottles. 


360  INFANT  FEEDING    (CHICAGO  METHODS) 

CLINIC  Vn.— BABY  14 

Age. — Five  months  two  weeks. 

The  diarrhea  has  gone,  and  the  bowels  move  once  a  day  and 
are  hard.    The  baby  is  hungry,  however. 

Weight. — Eight  pomids  three  omices,  showing  a  loss  of  one 
ounce  during  the  week. 

Temperature. — 98°  F. 

Examination. — No  change. 

Directions. — Increase  the  feeding  to — 

Milk 18  ounces 

Water 16  ounces 

Mellin's  Food 9  teaspoonf  uls 

Seven  feedings. 

CLINIC  Vm— BABY  14 

Child  much  better. 

Weight. — Eight  pounds  twelve  ounces,  showing  a  gain  of  nine 
ounces  in   the  week. 
Directions. — No  change.    In  a  few  days  start  cereal. 

CLINIC  L— BABY  15 
Brought  by  Dr.  W.  P.  Knight  (Greensboro) 

Age. — Two  years  two  months. 

History. — Family  and  past  history  negative.  The  complaint 
is  very  marked  constipation.  The  child  wouldn't  have  a  bowel 
movement  oftener  than  every  three  or  four  days  if  castor  oil 
or  enemas  weren't  given  continually. 

Weight. — Not  taken. 

Temperature.— 98.8°  F. 

Examination. — Negative. 

Discussion. — Gentlemen,  in  trying  to  diagnose  the  cause  of 
this'condition  let  us  think  of  the  simplest  things  first.  Let  us 
see  exactly  what  baby  has  been  eating. 

Question. — Mother,  how  do  you  feed  the  baby? 

Answer. — I  give  him  meat,  one  and  sometimes  two  eggs  a  day, 
a  little  broth,  some  toast,  once  in  a  while  some  corn-starch  or 
Cream  of  Wheat,  and  once  or  twice  a  week  a  baked  apple. 


CLINICS  361 

Question. — Don't  you  give  him  anything  else? 

Answer. — No. 

Question. — Don't  you  give  him  any  vegetables? 

Answer. — No,  my  book  on  feeding  said  I  shouldn't  use  any 
vegetables  until  he  was  over  two  years  of  age. 

Discussion. — Gentlemen,  you  see  how  simply  we  meet  many 
of  the  problems  in  pediatrics?  You  see  the  value  of  a  little 
simple  physiology?  Remember,  in  the  early  lectures  we  spoke 
of  fermentation  and  putrefaction.  Meat  and  eggs,  which  form 
a  large  part  of  this  baby's  diet,  are  protein  and  cause  an  alkaUne 
intestinal  reaction.  The  carbohydrate  which  the  baby  gets  is 
of  the  starchy  type,  and  normally  will  not  produce  much  fer- 
mentation. Again,  there  are  no  vegetables — not  enough  cellu- 
lose to  leave  a  residue  in  the  intestines.  I  think  the  treatment 
is  to  put  this  child  on  a  perfectly  full  diet,  perhaps  reducing  the 
meat  and  eggs  slightly,  giving  more  cereal,  particularly  oatmeal. 
By  all  means  give  plenty  of  vegetables,  even  the  coarser  ones, 
such  as  mashed  cabbage  and  turnips.  Give  baked  apple  or 
apple-sauce  every  day,  all  kinds  of  stewed  fruits,  and,  in  short, 
feed  the  baby  almost  everything  that  you  would  feed  an  adult, 
with  the  exception,  of  course,  of  the  very  heavy  things,  and  with 
the  provision  that  whatever  you  give  must  be  cut  up  fine. 
I  would  lay  particular  emphasis  upon  vegetables  and  stewed 
fruits.    Graham  crackers  are  considered  laxative. 

Now,  of  course,  this  baby  won't  react  tomorrow,  and  so,  imtil 
we  get  him  adjusted,  he  will  be  constipated.  Under  these  cir- 
cumstances let  him  go  for  perhaps  two  days,  and  then  give  an 
oil  enema.  Under  no  circumstances  give  him  any  more  pur- 
gatives. 

A  valuable  aid  in  children  of  this  age  is  a  combination  of  raw 
prunes,  dates,  figs,  and  raisins.  These  are  put  through  a  meat- 
grinder,  or  finely  chopped  in  a  chopping  bowl,  and  formed  into 
little  candy  balls.  Roll  them  in  a  little  powdered  sugar  and  they 
look  like  candy. 

In  this  case  we  may  need  some  malt  soup  extract  and  may  be 
some  mineral  oil  also. 


362  INFANT   FEEDING    (CHICAGO   METHODS) 

CLINIC  I— BABY  16 
Brought  by  Dr.  C.  W.  Woodson  (Salisbury) 

Age. — Fifteen  months. 

History. — Negative  except  for  the  following:  The  child  re- 
ceived the  breast  for  fourteen  months,  plus  a  mixed  diet  from 
the  eighth.  After  thriving  until  ten  months  he  developed 
measles  and  whooping-cough.  During  the  following  weeks  he 
lost  weight  and  became  puny,  but  his  bowels  were  all  right. 
Then  he  got  a  severe  diarrhea,  with  some  blood  in  the  stool. 
The  family  physician  treated  him  with  broth  and  albumin  water 
for  five  days.  Although  the  diarrhea  stopped,  he  got  much  worse 
on  this  diet.  Another  physician  was  called,  who  ordered  a  full 
diet.  The  child  again  grew  worse,  vomited,  had  severe  diarrhea, 
and  lost  rapidly.  The  parents,  in  desperation,  took  him  to  a 
neighboring  city.  Here  for  four  days  the  doctor  ordered  large 
quantities  of  oatmeal  water  and  buttermilk.  He  received  noth- 
ing else  durmg  that  time  and  gained  rapidly.  Two  or  three 
days  ago  another  doctor  was  called.  Although  the  child  had 
gained  at  an  enormous  rate,  he  was  very,  very  sick.  He  was 
suffering  severe  diarrhea,  temperature  was  97°  F.,  and  the  whole 
body  was  edematous.  The  last  physician  ordered  albumin  milk. 
On  this  he  has  lost  much  of  what  he  gained. 

Temperature. — 97°  F. 

Weight. — Ten  poimds. 

Examination. — This  shows  a  terribly  emaciated  child — the 
worst  we  have  seen.  Diffuse  rales  are  present  throughout  the 
chest. 

Discussion. — Gentlemen,  is  this  a  case  of  decomposition  due 
to  various  factors,  or  is  it  miliary  tuberculosis?  In  favor  of 
tuberculosis  is  the  history  of  measles  and  whooping-cough  and 
the  cUnical  picture,  with  the  rales  throughout  the  entire  chest. 
Against  this  diagnosis  are  the  absence  of  an  enlarged  liver  and 
spleen  and  the  absence  of  dulness  upon  direct  percussion  over 
the  spine — from  enlarged  bronchial  glands.  A  Pirquet  here 
would  not  help  us  because,  if  this  is  tuberculosis,  it  is  of  the 
miliary  type  and  would  give  a  negative  reaction.  The  only  sure 
way  is  to  introduce  a  cotton  swab  into  the  larynx,  obtain  sputum 
when  the  child  coughs,  and  make  smears. 


CLINICS  363 

In  favor  of  decomposition  of  the  mixed  type  we  have  the 
history  of  all  sorts  of  irregularities  in  feeding,  improper  diets, 
starvation,  recently  one-sided  carbohydrate  feeding,  plus  the 
secondary  influences  of  parenteral  infections,  as  measles  and 
whooping-cough,  and  even  possibly  definite  enteral  infection 
when  blood  appeared  in  the  stools.  The  cough  might  simply  be 
a  bronchitis  secondary  to  the  child's  weakened  condition. 

The  subnormal  temperature  doesn't  help  us,  for  it  may  be 
present  in  either  aUmentary  decomposition  or  in  the  collapse 
of  a  miliary  tuberculosis. 

In  either  case,  however,  whether  it  is  a  decomposition  due  to 
tuberculosis  or  to  alimentary  factors,  the  child  must  be  fed. 
Our  feeding  technic  will  be  the  same  as  in  decomposition. 

Directions. — Let  us  keep  him  on  albumin  milk  with  3  percent 
dextri-maltose.  Let  us  offer  protein  in  the  form  of  soft-boiled 
egg,  cottage  cheese,  curds  of  milk.  Let  us  offer  carbohydrate, 
as  mashed  potato,  zwieback,  and  corn-starch. 

Of  course,  remember  to  be  very,  very  careful  as  regards  quan- 
tity, and  certainly  not  start  more  than  one  new  food  on  the  same 
day.    I  believe  he  is  so  sick  we  might  try  three-hour  feedings. 

Give  the  child  all  the  water  he  wants  to  drink,  and  you  may 
have  to  stimulate  him. 

Let  us  see  him  next  week  if  he  is  still  with  us. 


CLINIC  n.— BABY  16 

Present  Age. — Fifteen  months  one  week. 

Present  Weight. — Twelve  pounds  nine  ounces,  a  gain  of  two 
pounds  nine  ounces  in  one  week. 

Mother  says  the  child  is  improved  in  every  way.  He  is 
brighter,  happier,  his  voice  is  stronger,  and  sometimes  he  smiles. 
She  has  noticed  his  great  gain.  He  hkes  his  food  and  wants 
more. 

Examination. — Shows  a  decided  improvement.  There  is  a 
suggestion  of  returning  elasticity  to  the  skin,  and  the  muscles, 
too,  begin  to  feel  more  hke  the  normal.  Doctor  reports  smears 
negative  for  tubercle  bacilli. 

Discussion. — Gentlemen,  from  the  standpoint  of  our  course, 
this  case  makes  a  most  excellent  conclusion.    Within  the  last 


364 


INFANT   FEEDING    (CHICAGO   METHODS) 


months  has  arisen  ahnost  every  compUcation  possible  in  the 
course  of  infant  feeding.  Let  us  picture  the  course  of  this  child 
by  the  following  curve  (Fig.  38) : 


IPTll. 

■M7. 

July. 

AVgOMt, 

~~^ 

20  lbs. 

XS  lbs. 

""^--v^      . 

i 

A, 

16  lbs. 

^                                      i 

4» 

i 

. 

^ 

V     1 

14  lbs 

i 

! 

1 

1 

/4  \ 

12  lb* 

o 

t 

a 

N 

10  lbs 

£ 

s 

£ 

t 

1 

\ 

/ '  \ 

Fig.  38. 


He  was  doing  nicely  until  he  suffered  a  parenteral  infection. 
Due  to  this,  his  nutrition  suffered  and  he  ceased  to  gain.  A 
severe  diarrhea  complicated  the  picture.  We  can't  say  whether 
this  was  an  infectious  diarrhea  or  one  resulting  from  the  paren- 
teral infection.  The  presence  of  bloody  stools  makes  us  suspect 
the  former.  The  weight  curve  suffered.  The  physician  treated 
the  stool  and  ordered  nothing  but  a  starvation  diet  for  five  days. 
The  stool  improved,  but  the  factor  of  severe  hunger,  added  to 
the  previous  injuries,  undoubtedly  was  sufficient  to  reduce  the 
child  to  a  condition  of  decomposition.  Now,  the  physician  not 
recognizing  the  fundamentals  of  the  case,  ordered  a  full  unre- 
stricted diet.  This  additional  insult  reduced  the  child  still  fur- 
ther and  he  was  taken  out  of  town.  In  a  neighboring  city,  a 
mixture  high  in  water,  carbohydrate,  and  salt  was  ordered. 
The  gain  in  weight  was  phenomenal,  but,  gentlemen,  this  gain 
in  weight  was  not  one  of  true  tissue  substance,  but  was  one  of 
water.  The  condition  of  decomposition  was  not  cured,  but  was 
masked.  The  water-logging  of  the  body  was  extreme — great 
enough  to  produce  a  marked  edema.  The  water,  however,  was 
bound  only  very  loosely  to  the  tissues.  The  baby  was  in  a  criti- 
cal condition,  with  subnormal  temperature  and  slow,  feeble 


CLINICS  365 

pulse.  The  feeding  then  ordered,  i.  e.,  albumin  milk,  a  mixture 
low  in  salts,  low  in  sugar,  just  the  reverse  of  the  previous,  caused 
a  complete  reversal  of  the  reaction.  The  organism  squeezed  out 
the  excess  of  fluid  with  which  it  previously  had  been  filled,  and 
the  baby  was  in  a  condition  identical  to  that  when  he  left  town. 
The  feeding  instituted  last  week,  taking  into  consideration  the 
needs  of  the  body  tissues,  answering  them  with  a  combination  not 
injuring  the  intestinal  tract,  has  apparently  worked  wonders. 
I  believe  this  child  will  recover.  I  am  very  proud  of  this  result, 
gentlemen,  and  I  should  advise  you  to  copy  this  curve  and  study 
it  carefully.    In  it  you  have  a  summary  of  our  entire  course. 

Question  by  Dr.  Flippen. — Before  concluding  this  part  of  the 
course,  would  you  mind  stating  precisely  once  more  just  what 
significance  you  place  upon  stool  examination? 

Answer. — Gross  examination  of  the  stool  will  aid  us,  first,  in 
distinguishing  the  infectious  from  the  nutritional  types  of  diar- 
rhea. The  infectious  types  usually  are  associated  with  blood, 
mucus,  pus,  and  rather  small,  soHd  contents  of  the  stool.  The 
nutritional  types  only  rarely  show  blood  or  pus.  Dysentery 
causes  alkaline  stools;  nutritional  diarrheas,  usually  acid.  Hav- 
ing ruled  out  infectious  disturbances,  the  condition  of  the  stool, 
whether  constipated  or  diarrheal,  is  of  value. 

The  constipated  stool  in  many  cases  may  mean  insufficient 
food  or  insufficient  fermentable  carbohydrate,  allowing  putre- 
factive processes  to  predominate,  or  may  mean  simply  insuffi- 
cient residue  in  the  intestinal  tract  from  excessive  resorption 
of  the  food.  It  must  be  considered  only  in  connection  with  the 
child's  weight  curve.  If  the  child  is  gaining,  the  stool  has  little 
significance. 

The  diarrheal  stool  usually  signifies  excessive  fermentation  in 
the  child's  intestinal  tract.  Whether  this  fermentation  be  due 
to  a  high  carbohydrate-whey  mixture,  to  parenteral  infec- 
tions, to  heat,  to  overfeeding,  or  to  other  factors,  our  history 
and  examination  will  disclose.  I  believe  I've  made  the  com- 
parison of  diarrheal  stools  to  coughs.  If  the  baby  coughs  once  or 
twice  a  day,  we  accept  this  as  evidence  of  irritation  of  the  re- 
spiratory tract,  but  don't  get  excited.  If  he  coughs  more  fre- 
quently but  has  no  fever  and  is  still  subjectively  well,  we  assume 
that  the  respiratory  irritation  is  worse,  but  still  are  not  alarmed, 


366  INFANT   FEEDING    (CHICAGO   METHODs) 

because  the  child  himself  is  not  suffering.  However,  when  he  not 
only  coughs  severely,  but  also  shows  other  reactions,  as  fever 
and  general  disturbance,  then  we  know  that  the  infection  is 
sufficient  to  affect  the  baby  as  a  whole.  So  it  is  with  these  diar- 
rheal stools.  When  the  child's  weight  curve  is  unaffected,  when 
the  child  clinically  is  well,  we  pay  little  attention.  Indeed,  we 
know  these  stools  may  be  symptoms  even  of  underfeeding,  but 
if  the  child,  on  the  other  hand,  appears  sick,  shows  changes  in 
his  general  behavior  and  conduct,  is  fretful,  and,  above  all  things, 
shows  changes  in  the  weight  curve  which  are  so  significant  of 
the  baby's  general  condition,  then  we  know  that  the  conditions 
in  the  intestinal  tract  are  sufficient  to  affect  the  baby  as  a 
whole. 

So,  gentlemen,  stool  examination  in  these  conditions  is  of 
importance,  but  it  is  of  importance  only  as  a  symptom,  and 
must  be  studied  not  by  itself,  but  only  in  connection  with  baby's 
history,  present  condition,  general  conduct,  and,  hy  all  means,  in 
connection  with  his  weight  curve. 


CONCLUSION 

Gentlemen :  This  concludes  the  main  chapters  of  the  course. 
These  lectures  and  clinics  have  leaned  possibly  a  little  more  to 
the  scientific,  a  little  less  to  the  practical.  This  was  absolutely 
intentional  on  my  part.  To  attempt  to  teach  you,  with  your 
years  of  experience  the  practice  of  medicine  would  be  absurd. 
You  know  better  than  I  the  Uttle  devices,  the  various  forms  of 
psychotherapy,  that  sustain  and  satisfy  anxious  patients.  In 
inanition,  if  the  mother  thinks  her  breast  milk  not  good,  satisfy 
her  by  obtaining  a  specimen  for  examination.  In  a  case  of 
overfeeding,  if  the  child  vomits,  give  a  little  placebo,  besides 
correcting  the  diet.  In  dyspepsia  order  a  mild  mixture  for  the 
bad  stools.  Only  in  families  of  the  highest  type  can  you  practise 
your  profession  without  some  sort  of  a  prescription.  In  the 
city,  as  well  as  in  the  country,  patients  want  medicine.  In 
this  course,  however,  I  have  omitted  all  these  details  because  I 
wanted  to  show  you  the  clear,  distinct  reactions.  The  disap- 
proving glances  of  our  good  nurses,  the  disappointment  of  the 
parents,  and  even  your  own  criticisms  ha,ve  not  escaped  me, 


CLINICS  367 

but  I  paid  no  heed,  for  I  wanted  to  teach  you  what  I  consider 
the  truth.  I  wanted  to  feel  that  after  the  conclusion  of  this 
course  no  one  would  be  justified  in  completely  overlooking  some 
of  the  essentials  in  diet  and  saying,  "  Such  and  such  a  result  was 
due  to  a  stomach  washing,  a  colonic  flushing,  a  dose  of  castor 
oil,  or  what  not,  given  coincidentally  with  the  change  of  food." 
We  have  attempted,  one  might  say,  a  laboratory  course,  un- 
trammeled  by  any  factors  which  might  cloud  the  pictures. 
Usually  a  haze  separates  us  from  our  patients,  a  haze  made 
of  false  conclusions  derived  from  superficial  examinations  and 
from  blind  adherence  to  antiquated  texts;  a  haze  invoked  by 
superstitious  grandparents,  and,  as  I  understand  it,  even  by 
some  of  your  newspapers  and  by  some  of  your  clergy  in  their 
unthinking  recommendation  of  proprietary  and  secret  remedies. 
I  have  tried  to  clear  away  this  mist;  to  reveal  the  patient  clear 
and  distinct  before  you;  to  show  you  the  truth,  as  I  see  it. 
Having  mastered  the  science  and  truth  of  medicine,  you  may,  if 
necessary,  adopt  the  various  devices  of  practice  with  impunity. 
Use  them,  but  don't  let  them  blind  you. 


INDEX 


Abnormal  breast-fed  baby,  25 

breast  milk,  23 
Absorption,  20 

toxic,  22 
Acetic  acid,  20 
Acetone,  99 

in    urine,    conditions    in    which 
found,  99 
test  for,  99 
Acetonuria,  99 
Acid,  acetic,  20 

butyric,  20,  156 

intoxication,  acidosis  in,  100 

lactic,  153 
Acidity  in  intestine,  20,  21 
Acidosis,  causes,  98 

definition,  98 

etiology,  101 

in  acid  intoxication,  100 

in  diarrhea,  79 

treatment,  101-103 

types  peculiar  to  children,  100 

usual  symptoms,  101 
Acids,  fatty,  164 
Adrenalin,  218 
Adulteration  of  milk,  154 
Agar-agar,  75 
Albumin  in  milk,  19 

milk  in  treatment  of  decomposi- 
tion, 233 
of  intoxication,  219 
preparation  of,  220 

technic    of    Langstein    and 
Meyer,  235 
Albumins,  153 
Alimentary  intoxication,  214 


Alkali  as  prevention  of  curd  forma- 
tion, 47 
in  treatment  of  acidosis,  102 
Alkalinity  in  intestine,  20,  21 
AlkaUs,  164 
Amino-acids,  163 

salts  of,  20 
Apple,  54 

Artificial  feeding,  27 
certified  milk  in,  27 
modification  of  milk  in,  29 
gravity  method,  30 
whole  method,  30 
of  normal  infant,  256 
pasteurized  milk  in,  28 
steriUzed  milk  in,  28,  29 


Babcock  quantitative  test  for  fat 

in  milk,  154 
Baby,  average,  caloric  needs  of,  21 

premature,  56-58 
Bacillus,  dysentery,  83 

gas,  83 

streptococcus,  83 
Bacteria,  action  of,  upon  carbohy- 
drates, 208 

in  intestine,  20,  208 

in  stools,  173 
Bacterial  growth  in  milk,  156 
Barley  jelly,  46 

water,  45 
Beef-juice,  53 
Bile,  20 

Bismuth  in  diarrhea,  81,  87 
Boiled  milk,  160,  162,  250,  254,  255 


42 


369 


370 


INDEX 


Bowels  of  new-bom  baby,  22 
Breast   and  bottle  feeding  mixed, 
case  illustrating,  142 
feeding,  21,  270 

amount  taken  in  twenty-foiu" 

hovu«,  23 
appearance  of  milk,  272 
contra-indications  for,  26,  270 
difficulties  in,  from  local  changes 
in  breast,  271 

from  standjx)int  of  child,  272 
dining  menstruation,  26,  274 
during  pregnancy,  26,  274 
first  few  weeks,  22 

of  newborn  baby,  22 

twenty-four  hours,  22 
intervals  for,  22 
modification  of  milk,  24 
quantity  of  milk,  24,  274,  275 
regularity  of,  22 
second  day,  22 

stimulation  of  breasts,  24,  273 
swallowing  of  air  during,  26,  277 
weaning,  26 
weight  in,  23 
wet-nurse,  27,  273 
milk,  abnormal,  23 
calcium  in,  169 
composition  of,  41,  155 
in  alimentary  intoxication,  221 
in  nutritional  disturbances,  198, 

201 
modification  of,  24 
quantity  of,  24,  274,  275 
scarcity  of,  24 
stimulation  of  production  of,  24, 

273 
time  of  appearance,  22,  272 
Breast-fed  baby,  abnormal,  25 

abnormal  bowel  movements  in, 

281 
colic  of,  25 

treatment  of,  26 


Breast-fed  baby,   constipation  in, 
282 
dyspepsia  in,  288 
etiology,  288 
symptoms,  288,  290 
treatment,  290 
inanition  in,  284 
diagnosis,  286 
etiology,  285 
prognosis,  286 
treatment,  287 
irregular  feeding  intervals,  26 
normal,  gain  in  weight  of,  24 
nutritional  disturbances  of,  25, 

280 
stools  of,  25 

substitute  feedings  for,  25 
imdemourishment  of,  25 
vomiting  in,  280 
Bulgar  tablets,  82 
Buttermilk,  220 

compMjsition  of,  48 
Butyric  acid,  20,  156 


Calcium,  112,  114,  164 
chlorid,  114,  115 
in  breast  milk,  169 
in  cow's  milk,  169 
lactate,  114 
Calomel,  75 

in  infectious  diarrheas,  252 
Caloric  needs  of  average  baby,  21, 
176 
production  of  fat,  21 
of  protein,  21 
of  sugar,  21 
value  of  foods,  176 

formula  for  calculating,  40 
Calorie,  39 

definition,  21 
Cane-sugar,  44 
Carbohydrates,  caloric  value  of,  176 


INDEX 


371 


Carbohydrates,  digestion  of,  165 

forms  of,  165 

functions  performed  by,  166 

in  milk,  153 

need  of,   in  nutritional  disturb- 
ances, 200 

relation  of,  to  water  in  body,  167 
Care  of  nursing  mother,  21 
Carpopedal  spasm,  113 
Casein,  45,  46,  153 

breast-milk,  19,  156 

cow's  milk,  19,  156 
Castor  oil,  22,  75 
Certified  milk,  27,  159 
Chapin  dipper,  32 
Chicken  soup,  53 
Chloral  in  diarrhea,  87 
Chvostek's  sign  in  spasmophilia,  113 
CUnics,  116-144;  293-367 
CoUc,  25 

Composition  of  milk,  19 
Condensed  milks,  50,  51 
Constipation,  72,  194,  195,  196 

causes  of,  72 

diet  in,  74 

drugs  in  treatment,  74,  203 

in  disturbances  of  breast-fed,  283 

laxatives  in,  74 

sugar  in  treatment,  202,  203 
Convulsions  in  spasmophilia,  113 
Craniotabes,  106 

Cream,  gravity,  composition  of,  32 
Curds,  156 

casein,  46 

in  stool,  160 

methods  for  preventing,  47 


Decomposition,     clinical    picture, 
224 
diagnosis,  230 

gastro-intestinal  symptoms,  226 
infection  in,  227,  228 


Decomposition,  metabolism  in,  229 
treatment,  233 

in  older  children,  239 
Dextrins,  44,  45,  165 
Diacetic  acid  in  urine,  test  for,  99 
Diarrhea,  acidosis  in,  100 
causes,  205,  208 

chronic  fermentative,  feeding  of 
eighteen-months-old  baby  with, 
case  illustrating,  128 
difference  between  infectious  and 

fermentative,  88 
fermentative,  77 
diet  in,  80 

due  to  protein,  82,  83 
in  small  baby,  case  illustrating, 

134 
stools  in,  78 
treatment,  80 
gas  bacillus  type,  87 
diet  in,  87 
test  for,  88 
high  sugar  diet  as  cause  of,  185, 

206 
infectious,  83,  249 
baciUi  in,  83 
calomel  in,  252 
case  illustrating,  85,  136 
dysentery  type,  84 
diet  in,  84 
treatment,  84 
reaction  to  food  in,  251 
stools  in,  251 
treatment,  251 
mechanical,  77 
nervous,  77 
of  infancy,  76 
starvation  in,  88 
summer,  78 
types  of,  208,  209 
whey  of  cow's  milk  in,  207 
Diet  in  constipation,  74 
in  fermentative  diarrhea,  80 


372 


INDEX 


Diet  in  infections  diarrhea,  84 
in  pyloric  spasm,  94 
in  pyloric  stenosis,  92 
list  at  thirteen  months,  55 

Children's    Hospital,    Boston, 

54 
for    eighteen    months'     baby, 

54 
sixteen  to  eighteen  months,  55 
twenty  to  twenty-two  months, 
55 
of  nursing  mother,  24 
Difference  between  cow's  milk  and 

breast  milk,  155 
Difficult  feeding  cases,  59 
Digestion,  disturbances  of,  61 
of  different  food  elements,  20 
of  milk,  163.     See  also  Milk,  di- 
gestion of. 
Disaccharid,  20,  165 
Disturbances  in  breast-fed,  280 
of  digestion,  61 

too  much  food  as  cause,  61 
of  nutrition,  modem  conception 
of,  178 
Drugs  in  constipation,  74,  203 
in  diarrhea,  81,  86 
in  spasmophiUa,  114 
Dysentery,  83 
treatment,  253 
dietetic,  253 

Frank,  for  infection  with  true, 
253,  254 
Dyspepsia,  209 
causes,  211 

in  disturbances  of  breast-fed,  288 
metabolism  in,  210 
starvation  in  treatment  of,  210, 

212 
states  of,  205 
treatment  of,  212 
weight  cur^e  in,  213,  214,  215 
whey  in,  207 


Eggs,  53 

Eisenzucker,  74 

Eiweiss,  48,  64,  219 

Electrical  reactions  in  diagnosis  of 

spasmophilia,  113 
End-products  in  intestine,  20,  21 
Enemas,  75 

suds,  26 
Energy  of  foods,  176 
Enteral  and  parenteral  infections. 

242 
Eskay's  Food,  50,  52 
Evaporated  milks,  51,  52 

Faxluiie  to  gain,  193 

carbohydrates  in,  199,  200 
constipation  in,  194,  195 
diagnosis,  201 
disturbed  balance  in,  200 
milk  injiuy  in,  194 

case  illustrating,  194 
treatment,  201 
Fat,  absorption  of,  20 

caloric  production  of,  21,  176 
digestion  of,  20,  164 
in  milk,  153 

Babcock's  quantitative  test  for, 
154 
in  stool,  164 
indigestion,  acute,  61 
chronic,  61 
stools  in,  71 
symptoms,  25 
intolerance,  case  illustrating,  68 
in  older  children,  67 
treatment,  62 

in  older  children,  67 
scrambled-egg  stool  type,  63 
soapy  stool  type,  62 
neutral,  20,  164 
of  cow's  milk,  156 
percentage  of,  for  normal  infant, 
43 


INDEX 


373 


Fat,  test  for,  in  stools,  72 
Fat-soap  stools,  195 
Fat- soaps,  164 
Fatty  acid,  20,  164 
Feces,  173.     See  also  Stools. 
Feeding,  percentage,  17,  18 
Fermentation,  157,  174,  199 
Food,  caloric  value  of,  formula  for 
calculating,  40 
composition  of,  42 
different  elements  of,  43 
digestion  of,  20 
fat,  43 
milk,  18,  153 
protein,  46 
starch,  45 
sugar,  44 
table  for  normal  infant,  42 
Foods,  energy  of,  176 
malted,  44,  45,  50 
proprietary,  49 
solid,  for  infant,  53 
Frank  treatment  for  infection,  with 

true  dysentery,  253,  254 
Fruit,  54 


Gas  bacillus  in  diarrhea,  83 
Globulins,  153 
Glucose,  165 


Harrison's  grooves,  106 
HorJick's  Malt  Food,  212,  236 

Malted  Milk,  50,  52       • 
Hunger  in  alimentary  intoxication, 
218 

in  decomposition,  227,  231 

in  dyspepsia,  210,  212 


Ileocolitis,  83 
Imperial  Granum,  50,  62 


Inanition,  284 

Indigestion,  chronic  sugar  and  fat, 
case  illustrating,  125 
fat,  acute,  61 
chronic,  61 
from  nervous  influences,  case  illus- 
trating, 118 
in  older  children,  67 
protein,  acute,  65 

chronic,  66 
starch,  chronic,  66 
sugar,  acute,  64 

chronic,  65 
too  much  food  as  cause,  61 
various  types,  59 
Infant,  normal,  feeding  of,  41 
premature,  56-58 
Welfare  Society,  267 
Infections,  parenteral  and  enteral, 
242 
anorexia  in,  248 
as  cause  of  increased  intestinal 

fermentation,  244 
diagnosis,  245 
treatment,  245 
vomiting  in,  247 
Infectious  diarrheas,  249.    See  also 

Diarrheas,  Infectious. 
Intestinal  antiseptics   in   diarrhea, 

82,87 
Intestine,  acidity  in,  20,  21 
alkalinity  in,  20,  21 
bacteria  in,  20,  208 
end-products  in,  20,  21 
Intoxication,  alimentary,  214 
diagnosis,  217 
treatment,  218 

in  older  children,  223 
states  of,  205 
whey  in,  207 
I  Intussusception,   cases  illustrating, 
96,97 
definition,  95 


374 


INDEX 


Intussusception,  stools  in,  95 

treatment,  96 

tumor  in,  95 
Iron,  68,  73 

Keller's  Malt  Soup,  195,  200,  281 
Kindolac,  50,  53 

Lactagogue,  272 
Lactic  acid,  153 

bacillus,  49 

milk,  49 
Lactose,  44,  153 
Larosan,  48 

Laxatives  in  constipation,  74 
Lime-water,  33,  47,  48 
Loeflund's  Malt  Soup  Extract,  45 


Magnesia,  milk  of,  75 
Magnesium,  164 
Malt  soup  extract,  203 
Malted  foods,  44,  45,  50 
Maltine  Malt  Soup,  45 
Maltose,  44,  45,  165 
Malt-sugar,  44,  45 
Meade's  Dextri-maltose,  45 
Meconium,  decomposition  of,  22 
Mellin's  Food,  45,  50,  52,  212,  236 
Metabolism  of  salt,  169 

of  water,  171 
Milk,  152 

adulteration  of,  154 
Babcock  test,  154 

albumin  in,  19 

bacterial  growth  in,  156 

boiled,  160,  162,  250,  254,  255 

breast,  23.     See  Breast  milk. 

casein  in,  19 

certified,  27,  159 

composition  of,  19,  153 
breast,  155 


Milk,  composition  of  cow's,  155 
cow's,  breast,  difference  between, 
155 

digestibility  of,  20 

protein  in,  46 
digestion  of,  163,  171 

carbohydrates  in,  165 

fat  in,  164 

protein  in,  163 

salts  in,  169 

sugars  in,  165 
evaporated,  51,  52 
food  elements  of,  18 
homogenized,  44 
in  gastro-intestinal  tract,  171 
injury,  Czemy's,  case  illustrating, 

194 
lactic  acid,  49 
mineral  matter  in,  168 
modification    of,    31.      See    also 

Modification  of  milk. 
of  magnesia,  75 
pasteurized,  28,  159 
proteins  in,  19 
skimmed,  composition  of,  32 
sterilized,  28,  29 
sugar  of,  20,  44,  153 
whole,  composition  of,  38 
Milk-borne  diseases,  157 
Mineral  matter  in  baby's  food,  168 
Modem  conception  of  disturbances 

of  nutrition,  178 
Modification  of  milk,  29,  30,  31-40 

gravity  method,  31,  32 

long  method,  33 

preparation  of  formula,  32,  33 

short  method,  35 

sugar  table  for,  36 

whole  method,  37 


Nervous     influences,     indigestion 
from,  case  illustrating,  118 


INDEX 


375 


Neutral  fat,  20 

New-bom  baby,  bowels  of,  22 

first  feeding  of,  22 
Nipples,    erosions   and   fissures   of, 

medicaments  for,  271 
Normal  infant,  feeding  of,  41 
artificial,  256 
interval  for,  257 
methods  of  Middle  West, 

260 
prophylactic  method,  260 
diet  lists,  54,  55 
fat  percentage  in,  43 
food  table  for,  42 
fruit  in,  54 
intervals  for,  42 
night  feedings,  43 
number  of,  42 
olive  oil  in,  44 
protein  in,  46 
solid  food,  53 
sugar  in,  44,  45 
twenty-four-hour  amount,  42 
vegetables  in,  54 
Nurse,  wet-,  qualifications  of,  27 
Nurses,  268 

Nvu-sing,  breast.    See  Breast  feeding. 
mother,  care  of,  21 
diet  of,  24,  278 
fluid  for,  278 
menstruation  of,  26 
nervous,  26 
pregnancy  in,  26 
Nutrition,  disturbances  of,  bacterio- 
logical classification,  180 
Czemy's   etiological   classifica- 
tion, 181 
diagnosis,  190 
fat  injury  in,  181 
Finkelstein's    classification    of 
food  disturbances,  184,  185 
latest  classification,  189 
milk  injury  in,  181 


Nutrition,  disturbances  of,  modern 
conception  of,  178 
pathological  classification,  179 
secondary,  due  to  parenteral  in- 
fections, 243,  244 
starch  injury  in,  181 
sugar  injury  in,  185 
Vienna  conception  of,  178,  179 
weight  curve  in,  183,  186,  192 
Nutritional  disturbances  of  breast- 
fed baby,  25,  26 
Nux  vomica,  68,  73 

Oatmeal  jelly,  46 

Olive  oil,  44 

Opium  in  diarrhea,  81,  87 

Orange-juice,  28,  29,  53,  54,  160 

in  treatment  of  scurvy,  110 
Overfeeding,  288,  289 

Pancreatic  juice,  20 

Parenteral  and   enteral  infections, 

242 
Pasteurization,  158 
Pasteurized  milk,  28 
Peptonization  of  milk,  47 
Percentage  feeding,  17,  18,  259 

calculation  of  formulae,  34 

principles  of,  89,  90 
Peristalsis,  increased  causes  of,  76 
Phenolphthalein,  75 
Pigeon-breast,  106 
Potato,  54 
Premature  babies,  56-58 

breast  milk  for,  56 

cow's  milk  for,  57 

indigestion  of,  58 

water  for,  58 
Proprietary  foods,  49 
Protein,  absorption  of,  20 
caloric  production  of,  21,  176 
content  of  breast  milk,  155 

of  cow's  milk,  155 


376 


INDEX 


Protein,  digestion  of,  20,  163 
in  food  for  normal  infant,  46 
in  milk,  19,  153 
in  urine,  164 
indigestion,  acute,  65 
chronic,  66 
stools,  in  66,  72 
symptoms,  25 
I*rune-juice,  53 

Purgatives  in  diarrhea,  81,  86 
Putrefaction,  157,  174,  199 
Pyloric  spasm,  definition,  91,  93 
physical  signs  of,  93 
treatment,  94 
stenosis,  definition,  91 
symptoms,  91 
treatment,  92 
Pylorospasm,  93 

Rachitis,  104.    See  also  Rickets. 
Rickets,  104 

acute,  case  illustrating,  139 

causes,  105 

definition,  104 

general  appearance,  106 

pathology,  104 

symptoms,  105 

treatment,  106 
Ridge's  Food,  50 

Saccharated  oxid  of  iron,  74 
Saccharose,  165 
Salt  metabolism,  169 
Salts,  digestion  of,  169 

in  breast  milk,  156 

in  cow's  milk,  156 

in  milk,  20,  153 

in  stool,  169 

of  amino-acids,  20 

relation  of,  to  water  in  body,  171 
Scrambled-egg  stools,  62,  63,  71 
Scurvy,  28,  29 


Scurvy,  diagnosis,  109 

pathology,  108 

symptoms,  109 

treatment,  110 

vitamins  in,  107 
Skimmed  milk,  32 
Soap  in  intestine,  20 

in  stool,  20 

stools,  62,  63,  71 
Soaps,  fat-,  164 
Sodium  bicarbonate,  47,  48 

bromid  in  diarrhea,  87 

citrate,  47,  48 
Spasmophilia,  definition.  111 

diagnosis,  112,  113 

etiology.  111 

prognosis,  113 

treatment,  114 

Trousseau's  symptom  in,  113 
Starch  in  food  for  normal  infant,  45 

indigestion,  chronic,  66 
stools  in,  66,  72 

intolerance  in  older  children,  70 

test  for,  in  stools,  73 
Starvation,  59 

in   treatment   of   alimentary   in- 
toxication, 218 
of  dyspepsia,  210,  212 
Sterihzed  milk,  28,  29 
Stomach,  digestion  in,  20 
Stools,  173 

abnormal,  types  of,  71 

bacteria  in,  173 

ciu-ds  in,  160 

fat  in,  164 

in  constipation,  74 

in  decomposition,  226,  227 

in  disturbances  in  breast-fed,  281- 
283 

in  fat  indigestion,  71 

in  fermentative  diarrhea,  78 

in  infancy,  70 

in  infectious  diarrheas,  251 


INDEX 


377 


Stools  in  protein  indigestion,  66,  72 

in  starch  indigestion,  66,  72 
intolerance,  70 

in  sugar  indigestion,  72 

microscopic  examination  of,  72 

oUy,  71 

of  breast-fed  baby,  25 

salts  in,  169 

scrambled-egg,  62,  63 

secondary  products  in,  175 

soapy,  62,  63,  71 

unabsorbed  foodstuffs  in,  1 74 
Streptococcus  bacillus  in  diarrhea, 

83 
Sucrose,  44 
Suds  enema,  26 
Sugar,  44 

absorption  of,  20 

caloric  production  of,  21 

child's  need  of,  166,  167 

complex,  20 

diet,  high,  as  cause  of  diarrhea, 
185,206 

digestion  of,  20,  165 

forms  of,  165 

in  food  for  normal  infant,  44 

in  stools,  20 

indigestion,  acute,  64 
chronic,  65 
stools  in,  66,  72 

of  milk,  20,  44,  153 

relation  of,  to  temperature,  168 

table,  36 
Suppositories,  75 


Temperature,  relation  of  sugars  to, 
168 

Tetany,  111.    See  also  Sjxismophilia. 

Toasted  bread,  53 

Toxic  absorption,  22 

Trousseau's  symptom  in  spasmo- 
philia, 113 


Undernourishment  of  breast-fed 

baby,  25,  26 
Urine,  acetone  in,  99 

diacetic  acid  in,  99 

in  acidosis,  100 

protein  in,  164 

Vegetables,  54 

Vitamins,  absence  of,  as  cause  of 

sciu^y,  107 
Vomiting    from    irregular    feeding, 
case  illustrating,  116 

in  disturbances  of  breast-fed,  280 

obstinate,      from      feeding     too 
quickly,  case  illustrating,  121 

projectile,  91 

recmrent,  acetone  in  urine  in,  100 

Water  and  carbohydrates,  167 

barley,  45 

content  of  whole  milk,  38 

gain  in  weight  from,  167 

in  body,  relation  of  salts  to,  171 

in  milk,  154 

metabolism,  171 

supply  in  inanition,  288 
Weaning,  26 

Weight    curve   in   nutritional   dis- 
turbances, 183 
in  parenteral  infections,  245 

gain  in,  from  water,  167 

in  disturbances  of  nutrition,  186 

of  normal  breast-fed  baby,  24 
Wet-nxirse,  quaUfications  of,  27 
Whey,  composition  of,  46 

in  dyspepsia,  207 

in  intoxication,  207 

of  cow's  milk,  in  nutritional  dis- 
turbance, 206,  207 

preparation  of,  47 
Whole  milk,  38 

Zwieback,  53 


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hold. It  gives  you  hundreds  of  valuable  points  on  the  business  management 
of  hospitals — large  and  small. 


Allen's  Local  Anesthesia 

Local  Anesthesia.  By  Carroll  W.  Allen,  M.  D.,  In- 
structor in  Clinical  Surgery  at  Tulane  University  of  Louisiana. 
Octavo  of  625  pages,  illustrated.     Cloth,  ^6.00  net. 

ILLUSTRATED 

This  is  a  complete  work  on  this  subject.  You  get  the  history  of  local 
anesthesia,  a  chapter  on  nerves  and  sensation,  giving  particular  attention  to 
pain — what  it  is  and  its  psychic  control.  Then  comes  a  chapter  on  osmosis 
and  diffusion.  Each  local  anesthetic  is  taicen  up  in  detail,  giving  very  special 
attention  to  cocain  and  novocain,  pointing  out  the  action  on  the  nervous  system, 
the  value  of  adrenalin,  paralysis  caused  by  cocain  anesthesia,  control  of  tox- 
icity. You  get  Crile's  method  of  administering  adrenalin  and  salt  solution, 
the  exact  way  to  produce  the  intradermal  wheal,  to  pinch  the  flesh  for  the  inser- 
tion of  the  needle— all  shown  you  step  by  step.  You  get  an  article  on  anoci- 
association,  the  production  of  local  anesthesia  in  the  various  regions,  spinal 
analgesia,  and  epidural  injections.    There  is  a  large  section  on  dental  anesthesia. 


SAUXDERS"    BOOKS   ON 


Moynihan's  Abdominal  Operations 

Abdominal  Operations.  By  Sir  Berkeley  Moynihan,  M.  S.  (Lon- 
don), F.  R.  C.  S.,  of  Leeds,  England.  Two  octavos  of  500  pages  each, 
with  385  illustrations,  5  in  colors.     Per  set:  Cloth,  $11.00  net.  * 

THIRD  EDITION,  RESET 

This  new  edition  has  been  issued  after  a  most  thorough  revision — so  thorough  that 
the  work  had  to  be  reset  and  issued  in  two  handsome  volumes.  Over  150  pages  of 
new  matter  and  80  new  illustiations  were  added.  Two  new  chapters  arc  those  on 
excision  of  gastric  ulcer  and  complete  gastrectomy.  Some  p5  illustrative  cases  are  dis- 
tributed throughout  the  work,  giving  every  detail,  history,  examination,  operation, 
complications,  results.  These  are  extremely  instructive.  Moynihan's  definite, 
didactic  style,  together  with  the  large  number  of  practical  illustrations  and  the 
illustrative  cases  make  this  work  the  most  useful  abdominal  surgery  published. 
Each  volume  has  stamped  on  its  back  the  subjects  treated  therein,  thus  facilitating 
quick  consultation. 


Moynihan's  Duodenal  Ulcer  Edwon 

DuoDEN.\L  Ulcer.  By  Sir  Berkeley  Moynihan",  M.  S.  (Lon- 
don), F.  R.  C.  S.,  o£  Leeds,  England.  Oclavo  of  486  pages,  illus- 
trated.    Cloth,  $5.00  net. 

"  Easily  the  best  work  on  the  subject  ;  coining,  as  it  does,  from  the  pen  of  one  of 
the  masters  of  surgery  of  the  upper  abdomen,  it  may  be  accepted  as  authoritative." 
— The  London  Lancet. 

Moynihan  on  Gall-stones  I^Son 

Gall-stones  and  Their  Surgical  Treatment.  By  Sir  Berkeley 
Moynihan,  M.  S.  (Lontjon),  F.  R.  C.  S.  Octavo  of  458  pages,  illus- 
trated.    Cloth,  $5.00  net. 

"  He  expresses  his  views  with  admirable  clearness,  and  he  supports  them  by  a 
large  number  of  clinical  examples,  which  will  be  much  prized  by  those  who  know 
the  diflBcult  problems  and  tasks  which  gall-stone  surgery  not  infrequently  presents." 
— British  Medical  Journal. 


SURGERY  AND  ANATOMY 


Crandon  and  Ehrenfried's 
Surgical    After-treatment 

Surgical  After-treatment.  By  L.  R.  G.  Crandon,  M.  D., 
Assistant  in  Surgery,  and  Albert  Ehrenfried,  M.  D.,  Assistant 
in  Anatomy,  Harvard  Medical  School,  Octavo  of  831  pages, 
with  265  original  illustrations.  Cloth,  ^6.00  net. 

THE  NEW  (2d)  EDITION 

This  worK  tells  how  best  to  manage  all  problems  and  emergencies  of  sur- 
gical convalescence  from  recovery-room  to  discharge.  It  gives  all  the  details 
completely,  definitely,  yet  concisely,  and  does  not  refer  the  reader  to  some 
other  worK  perhaps  not  then  available.  The  postoperative  conduct  of  all 
operations  's  given.  There  is  an  elaborate  chapter  on  Vaccine  Therapy,  Im- 
munization by  Inoculation,  and  Specific  Sera,  by  Dr.  George  P.  Sanborn. 
Therapsutic  Gazette 

"  This  book  is  one  which  can  be  read  with  profit  by  the  active  surgeon  and  practitioner 
and  will  be  generally  commended." 


Mayo  Clinic  Papers 

Mayo  Clinic  Papers.  By  William  J.  Mayo,  M.  D., 
Charles  H.  Mayo,  M.  D.,  and  their  Associates  at  The  Mayo 
Clinic,  Rochester,  Minn.  Papers  of  1905-09,  1910,  191 1,  1912, 
1913.     Each,  ^5.50  net.     Papers  of  1916  preparing. 


A  Collection  of  Papers  (published  previous  to  1909).  By 
W.  J.  and  C.  H.  Mayo.  Two  octavos  of  525  pages  each,  illus- 
trated.    Per  set :   Cloth,  ;gi  0.00  net. 


SAUNDERS'  BOOKS  ON 


Keen's  New  Surg'ery 

Surgery :  Its  Principles  and  Practice.  Written  by  82 
eminent  specialists.  Edited  by  W.  W.  Keen,  M.  D.,  LL'  D., 
Hon.  F.  R.  C.  S.,  Eng.  and  Edin.,  Emeritus  Professor  of  the 
Principles  of  Surgery  and  of  Clinical  Surgery  at  the  Jefferson 
Medical  College,  Philadelphia.  Six  large  octavo  volumes  oi 
over  1050  pages  each,  containing  3100  illustrations,  157  in  colors. 
Per  volume:   Cloth,  $7.00  net;   Half  Morocco,  $8.00  net. 

VOLUME  VI  GIVES  YOU  THE  NEWEST  SURGERY 

In  this  sixth  volume  you  get  all  the  newest  surgery — both  general  and 
special — from  the  pens  of  thuac  same  international  authorities  who  have  made 
the  success  of  Keen's  Surgery  world-wide.  Each  man  has  searched  for  the 
new,  the  really  useful,  in  his  particular  field,  and  he  gives  it  to  you  here. 
Here  you  get  the  newest  surgery,  and  fully  illustrated.  Then,  further,  you 
get  a  complete  index  to  the  entire  six  volumes,  covering  125  pages,  but  so 
arranged  that  reference  to  it  is  extremely  easy.  If  you  want  the  newest  sur- 
gery, you  must  turn  to  the  new  "  Keen  "  for  it. 


Moorhead's 
Traumatic  Surgery 

Traumatic  Surgery.  By  John  J.  Moorhead,  M.  D., 
Adjunct  Professor  of  Surgery,  New  York  Post-Graduate  Medical 
School  and  Hospital.  Octavo  of  760  pages,  with  520  original 
line-drawings.  Just  Ready.  Cloth,  $6.50  net. 

WITH  522  ORIGINAL  LINE-DRAWINGS 

This  work  has  a  wide  appeal.  It  appeals  to  the  surgeon,  the  prac- 
titioner, the  mining,  railroad,  and  industrial  physician,  those  having  to  do 
with  Compensation  Law,  accident  insurance  and  claims,  and  legal  medicine. 
But  its  greatest  appeal  is  to  the  general  practitioner — the  man  in  general  prac- 
tice anywhere — because  practically  the  entire  work  is  devoted  to  Minor  Sur- 
gery— those  traumatic  conditions  that  form  a  part  of  ever)'  doctor's  daily  prac- 
tice. The  work  is  original  in  text,  illustrations,  arrangement,  and  method  of 
presentation.  Only  those  treatments  are  given  which  Dr.  Moorhead  has 
found  successful. 


SURGER  Y  AND  ANA  TO  MY 


Scudder's  Fractures 

WITH   NOTES   ON   DISLOCATIONS 


The  Treatment  of  Fractures  :  with  Notes  on  a  few  Com- 
mon Dislocations.  By  Charles  L.  Scudder,  M.  D.,  Surgeon  to 
the  Massachusetts  General  Hospital,  Boston.  Octave  volume  of 
735  P^gss,  with  1057  illustrations.     Polished  Buckram,  ^6.00  net. 

THE  NEW  (8th)  EDITION,  ENLARGED 

OVER  35.000  COPIES 

Seven  large  editions  of  this  remarkable  book  is  a  decisive  indication 
of  the  value  of  Dr.  Scudder' s  work.  For  this  new  edition  numerous  ad- 
ditions have  been  made  throughout  the  text  and  a  large  number  of  new 
illustrations  added,  greatly  enhancing  the  value  of  the  work.  In  every  way 
this  edition  reflects  the  very  latest  advances  in  the  treatment  of  fractures. 
J,  F.  Binnie.  M.  D.,  formerly  University  of  Kansas. 

"  Scudder's  Fractures  is  the  most  successfnl  book  on  the  subject  that  has  ever  been 
published.     I  keep  it  at  hand  regularly." 


Scudder's  Tumors  of  the  Jaws 

Tumors  of  the  Jaws.  By  Charles  L.  Scudder,  M.  D., 
Surgeon  to  the  Massachusetts  General  Hospital,  Boston.  Octavo 
of  395  pages,  with  353  illustrations,  6  in  colors.     Cloth,  ^6.50  net. 

WITH  NEW  ILLUSTRATIONS 

Dr.  Scudder  in  this  book  tells  you  how  to  determine  in  each  case  the 
form  of  new  growth  present,  and  then  points  out  the  best  treatment.  As  the 
tendency  of  malignant  disease  of  the  jaws  is  to  grow  into  the  accessory  sinuses 
and  toward  the  base  of  the  skull,  an  intimate  knowledge  of  the  anatomy  of 
these  sinuses  is  essential.  Dr.  Scudder  has  included,  therefore,  sufficient 
anatomy  and  a  number  of  illustrations  of  an  anatomic  nature.  Whether  gen- 
eral practitioner  or  surgeon,  you  need  this  new  book  because  it  gives  you  just 
the  iaformation  you  want. 


SAUNDERS'    BOOKS    ON 


Cotton's 
Dislocations  anl  Joint  Fractures 


Dislocations  and  Joint  Fractures.  By  Frederic  Jay 
Cotton,  A.  M.,  M.  D.,  First  Assistant  Surgeon  to  the  Boston 
City  Hospital.  Octavo  volume  of  654  pages,  with  1201  original 
illustrations.     Cloth,  $6.00  net. 

TWO  PRINTINGS  IN  EIGHT  MONTHS 

Dr.  Cotton's  clinical  and  teaching  experience  in  this  field  has  especially 
fitted  him  to  write  a  practical  work  on  this  subject.  He  has  written  a  book 
clear  and  definite  in  style,  systematic  in  presentation,  and  accurate  in  state- 
ment. The  author  is  himself  the  artist,  so  that  the  illustrations  show  just 
those  points  he  wished  to  emphasize. 

Boston  Medical  and  Surgical  Jotimal 

"The  work  is  delishtfu!.  spirited,  scholarly,  and  original.  It  brings  the  subjects  up 
to  date — a  feat  long  neglected." 


Elsber^'s 
Surg'ery  of  Spinal  Cord 

Diagnosis  and  Treatment  of  Surgical  Diseases  of  the 
Spinal  Cord  and  its  Membranes.  Octavo  of  330  pages,  with 
158  illustrations,  3  of  them  in  colors.  By  Ch.^rles  A.  Elsberg, 
M.  D.,  Professor  of  Clinical  Surgery,  New  York  University  and 
Belle vue  Hospital  Medical  School.     Cloth,  $5.00  net. 

INCLUDING  USE  OF  X-RAYS 

There  is  no  other  book  published  like  this  by  Dr.  Elsberg.  It  gives  you 
in  clear  definite  language  the  diagnosis  and  treatment  of  all  surgical  diseases 
of  the  spinal  cord  and  its  membranes,  illustrating  each  operation  with  original 
pictures.  Because  it  goes  so  thoroughly  into  Symptomatology,  diagnosis,  and 
indications  for  operation  this  work  appeals  as  strongly  to  the  general  prac- 
titioner and  neurologist  as  to  the  surgeon.  The  first  part  of  the  work  is  de- 
voted to  anatomy  and  physiology  of  the  spinal  cord,  and  to  the  symptomatology 
of  surgical  spinal  diseases.  The  second  part  takes  up  operations  upon  the 
spine,  the  cord,  and  nerve-roots.  The  third  part  is  given  over  to  surgical  dis- 
eases of  the  cord  and  its  membranes — their  diagnosis  and  treatment.  In- 
cluded also  are  chapters  on  hematomyelia  and  spinal  gliosis,  because  in  these 
diseases  much  harm  is  done  to  the  fiber  tracts  by  compression. 


SUJiGER  V  AND  ANA  TOMY 


Kelly  and  Noble's  Gynecology 
and  Abdominal  Surg'ery 

Gynecology  and  Abdominal  Surgery.  Edited  by  Howard 
A.  Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins 
University;  and  Charles  P.  Noble,  M.  D.,  formerly  Clinical 
Professor  of  Gynecology,  Woman's  Medical  College,  Philadel- 
phia. Two  imperial  octavos  of  950  pages  each,  with  880  illustra- 
tions.    Per  volume :  Cloth,  ^8.00  net ;  Half  Morocco,  $9.50  net. 

WITH  880  ILLUSTRATIONS  BY  BECKER  AND  BRODEL 

This  work  possesses  a  number  of  valuable  features  not  to  be  found  in  any 
other  publication  covering  the  same  fields.  It  contains  a  chapter  upon  the 
bacteriology  and  one  upon  the  pathology  of  gynecology,  and  a  large  chapter 
devoted  entirely  to  medical  gynecology,  written  especially  for  the  physician 
engaged  in  general  practice.  Abdominal  surgery  proper,  as  distinct  from 
gynecology,  is  fully  treated,  embracing  operations  upon  the  stomach,  intes- 
tines, liver,  bile-ducts,  pancreas,  spleen,  kidneys,  ureter,  bladder,  and  peri- 
toneum. 

American  Journal  of  Medical  Sciences 

"It  is  needless  to  say  that  the  work  has  been  thoroughly  done ;  the  names  of  the 
authors  and  editors  would  guarantee  this,  but  much  may  be  said  in  praise  of  the  method 
of  presentation ;  and  attention  may  be  called  to  the  inclusion  of  matter  not  to  be  found 
elsewhere." 


Crile  and  Lower's  Anoci-Association 

Anoci- Association  is  the  new  way  of  anesthetizing.  It  pre- 
vents shock,  it  robs  surgery  of  its  harshness,  it  diminishes  post- 
operative mortality,  it  lessens  the  likelihood  of  nausea,  vomit- 
ing, gas-pains,  backache,  nephritis,  pneumonia,  and  other  post- 
operative complications.  You  get  anoci-association  and  blood- 
pressure  and  the  technic  of  nitrous-oxid  oxygen  anesthesia. 

Octavo  of  27s  pages,  illustrated.  By  George  W.  Crile,  M.  D.,  Professor  of  Surgery, 
and  Wn-LUM  E.  Lower,  M.  D.,  Associate  Professor  of  Genito-Urinary  Surgery,  Western 
Reserve  University.    Cloth,  $3-00  net. 


SAUNDERS'    BOOKS   ON 


Mumford's 
Practice   of  Surgery 

The  Practice  of  Surgery.  By  James  G.  Mumford,  M.  D., 
formerly  Lecturer  on  Surgery,  Harvard  Medical  School.  Octavo 
of  1032  pages,  with  683  illustrations.      Cloth,  $7.00  net. 

SECOND  EDITION 

This  is  a  clinical  surgery,  giving  those  methods  and  operations  which  the 
author  has  personally  followed  for  the  past  twenty  years.  The  plan  of  the 
work  is  somewhat  off  the  conventional  lines,  the  diseases  being  taken  up  in 
Iheir  order  of  interest,  importance,  and  frequency. 

John    B.    Murphy,   M.  D.,  Northwestern  Medical  School,  Chicago 

'This  work  truly  represents  Dr.  Mumford's  intellectual  capacity  and  scope,  and  pre- 
sents in  a  terse,  forceful,  yet  pleasing  manner,  the  live  surgical  topics  of  the  day.  It  is  in 
every  particular  up  to  date." 


DaCosta's  Modern  Surgery 

Modern  Surgery — General  and  Operative.  By  John 
Chalmers  DaCosta,  M.  D.,  Samuel  D.  Gross  Professor  of  Sur- 
gery, Jefferson  Medical  College,  Philadelphia.  Octavo  of  15 15 
pages,  with  1085  illustrations.  Cloth,  $6.00  net;  Half  Morocco, 
$7.50  net. 

SEVENTH  EDITION 

A  surgery,  to  be  of  the  maximum  value,  must  be  up  to  date,  must  be  com- 
plete, must  have  behind  its  statements  the  sure  authority  of  experience,  must 
be  so  arranged  that  it  can  be  consulted  quickly ;  in  a  word,  it  must  be  practical 
and  dependable.  Such  a  surgery  is  DaCosta's.  Always  an  excellent  work 
for  this  edition  it  has  been  very  materially  improved  by  the  addition  of  much 
new  matter  and  many  additional  illustrations. 

Rudolph  Matas,  M.D.,  Professor  of  Surgery,  Tulane  University  of  Louisiana, 

"  This  edition  is  destined  to  rank  as  high  as  its  predecessors,  which  have  placed  the 
learned  author  in  the  fore  of  text-book  writers.  The  more  I  scrutinize  its  pages  the  more  I 
admire  the  marvelous  capacity  of  the  author  to  compress  so  much  knowledge  in  so  small  » 
space." 


SURGERY  AND  ANATOMY 


Cullen's 
Diseases  of  the  Umbilicus 

Embryology,  Anatomy,  and  Diseases  of  the  Um- 
bilicus ;  together  with  Diseases  of  the  Urachus.  By  Thomas 
Stephen  Cullen,  M.  B.,  Associate  Professor  of  Gynecology  in 
the  Johns  Hopkins  University.  8vo  of  680  pages,  with  269  illus- 
trations.    Cloth,  1^7.50  net;   Half  Morocco,  $9.00  net. 

ILLUSTRATED  BY  MAX  BRODEL 

This  new  monograph  appeals  to  the  anatomist,  pediatrician,,  surgeon, 
genito-urinary  specialist,  and  practitioner.  Conditions  of  the  umbilicus 
have  always  been  more  or  less  the  "X"  of  general  practice.  This  book  ex- 
plains these  unknown  conditions,  presenting  thoroughly  every  disease  in 
any  way  associated  with  the  lunbilicus,  and  making  the  entire  subject 
strikingly  clear. 


Crile's  The  Kinetic  Drive        Recently  issued 

The  Kinetic  Drive.  By  George  W.  Crile,  M.  D.,  Professor  of 
Surgery,  Western  Reserve  University,  Cleveland.  Octavo  of  71  pages, 
illustrated.     Cloth,  $2.00  net. 

In  this  book  Dr.  Crile  analyzes  the  mechanism  by  which  the  present-day  industrial 
and  commercial  "spyeeding"  is  accomplished,  and  relates  it  to  the  speeding  due  toother 
stimuli,  such  as  infections,  auto-intoxication,  physical  injury,  etc.    The  work  is  timely. 

Montgomery's  Care  of  Surgical  Patients 

Care  of  Patients  :  Before,  During,  and  After  Operation.  By  E. 
E.  Montgomery,  M.  D.,  LL.  D.,  Professor  of  Gynecology  in  Jefferson 
Medical  College.     i2mo  of  149  pages,  illustrated.     Cloth,  $1.25  net. 

This  book  gives  you  many  hints  and  suggestions  acquired  during  many  years  of 
operative  work.  Its  use  will  lessen  the  anxiety  of  the  surgeon,  promote  better  work, 
facilitate  the  labor  of  nurses  and  interns,  and  add  to  the  comfort  and  satisfaction  of 
the  patient. 

Rad&sch's  Anatomy  R«»dy  soon 

Ma.nual  of  Anatomy.  By  Henry  E.  Radasch,  M.  D.,  Assistant 
Professor  of  Histology  and  Biology,  Jefferson  Medical  College.  Octavo 
of  500  pages,  profusely  illustrated. 

Dr.  Radasch 's  new  handbook  is  complete  in  both  text  and  illustrations.  Every 
effort  has  been  taken  to  make  the  study  of  anatomy  boih  easy  and  interesting  the 
many  illustrations  contributing  markedly  to  this  end.  ' 


SAUNDERS'  BOOKS  ON 


Cushing's  Tumors  of  the  Brain      in?u1y 

Tumors  of  the  Nervus  Acusticus  and  the  Syndrome  of 
the  Cerebellopontine  Angle.  By  H/Vrvey  Gushing,  M.  D., 
Surgeon-in-Chief,  Peter  Bent  Brigham  Hospital,  Boston. 
Octavo  of  350  pages,  fully  illustrated. 

A  FULLY  ILLUSTRATED  STUDY 

Dr.  Gushing  presents  here  an  exhaustive  study  of  tumors  of  the  accustic 
nerve.  He  gives  you  his  own  technic,  and  the  results  of  study  and  ob- 
servation of  some  thirty  cases.  These  tumors,  despite  the  fact  that  they 
are  comparatively  common,  are  imperfectly  understood,  and  the  present 
volume  is  a  thorough  presentation  of  the  subject,  embracing  history,  ana- 
lysis of  symptoms,  physical  examination,  morphology,  histology,  and  opera- 
tive technic — in  short,  every  aspect  of  the  cases  clearly  and  completely 
covered.  You  are  given  not  onlj'  the  surgical  aspects,  but  the  historical, 
symptomatic,  and  pathologic  as  well.  The  illustrations  are  particularly 
noteworthy;  they  are  plentiful,  practical,  and  definitely  valuable.  !Many 
show  the  successive  steps  in  operation,  demonstrating  as  nothing  else  can 
tlje  exact  technic  that  makes  for  the  successful  outcome. 


Owen's  Treatment  of  Emergencies    out 

The  Treatment  of  Emergencies.  By  Hubley  R.  Owen, 
M.  D.,  Surgeon  to  the  Philadelphia  General  Hospital.  i2mo 
of  560  pages,  with  249  illustrations. 

A  COMPLETE  TREATMENT 

Dr.  Owen's  book  gives  you  not  only  the  achial  technic  of  the  pro- 
cedures, but,  what  is  equally  important,  the  underlying  principles  of  the 
treatments,  and  the  reason  why  a  particular  method  is  advised.  You  get 
chapters  on  fractures  of  all  kinds,  going  fully  into  symptoms,  treatments, 
and  complications.  You  get  treatments  of  contusions,  of  wounds,  both 
lacerated  and  incised.  Particularly  strong  is  the  chapter  on  gun-shot 
wounds,  which  gives  the  new  treatments  that  the  great  European  War  has 
develof)ed.  You  get  the  principles  of  hemorrhage,  together  with  its  con- 
stitutional and  local  treatments.  You  get  chapters  on  sprains,  disloca- 
tions, burns,  sunburn,  chilblain,  asphyxiation,  convulsions,  hysteria,  apo- 
plexy, exhaustion,  opium  poisoning,  uremia,  and  electric  shock.  You  get 
sections  on  bandages,  and  a  complete  discussion  of  artificial  respiration, 
including  mechanical  devices.  The  book  is  complete;  it  is  thorough;  it  is 
practical. 


SURGERY  AND  ANATOMY  13 

D&nnreuther's  Emergency  Surgery 

Minor  and  Emergency  Surgery.  By  Walter  T.  Dannreuther, 
M.  D.,  Surgeon  to  St.  Elizabeth's  Hospital  and  to  St.  Bartholomew's 
Clinic,  New  York  City.  i2mo  of  225  pages,  illustrated.  Cloth,  $1.25 
net. 

Fowler's  Operating  Room  Third  Edition 

The  Operating  Room  and  the  Patient.  By  Rlssell  S.  Fowler, 
M.  D.,  Chief  Surgeon,  First  Division,  German  Hospital,  Brooklyn,  New 
York.     Octavo  of  6 II. pages,  illustrated.     Cloth,  $3.50  net. 

Keen's  Addresses  and  Other  Papers 

Addresses  and  Other  Papers.  Delivered  by  William  W.  Keen. 
M.  D.,  LL.D..  F.  R.  C.  S.  (Hon.).  Professor  of  the  Principles  of  Surgery 
and  of  Clinical  Sureerv.  Jefferson  Medical  College,  Philadelj^hia.  Octavo 
volume  of  441   pages,  il]u.-.tra!ed.     Cloth,  $3.75  net. 

Keen  on  the  Surgery  of  Typhoid 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever. 
By  Wm.  W.  Keen,  M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of 
the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical 
College,  Philadelphia,  etc.  Octavo  volume  of  386  pages,  illustrated. 
Cloth,  ^3.00  net. 

American  Text -Book  of  Surgery  Fourth  Edition 

American  Text-  Book  ok  Surgery.  Edited  by  W.  W.  Kekn,  M  .  D., 
LL.  D.,  Hon.  F.  R.  C.  S.,  Eng.  and  Edin.;  and  J.  William  White, 
M.  D.,  Ph.  D.  Octavo,  1363  pages,  551  text-cuts  and  39  colored  and 
half-tone  plates.      Cloth,  $7.00  net ;    Half  Morocco,  $%.^0  net. 

Nancrede's  Essentials  of  Anatomy  8th  Edition 

Essentials  of  An.\tomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  University  of  Michigan,  Ann  Arbor.  Crown  octavo,  430 
pages,  155  cuts.  Based  on  Gray's  Anatomy.  Cloth,  $1.25  net.  In 
Saunders'  Question  Compends. 

Whiting's   Bandaging  Recently  issued 

This  new  work  takes  up  each  bandage  in  detail,  telling  you — and 
jAcww'wo^  you  by  original  illustrations — just  how  each  bandage  should  be 
ap|)lied,   each    turn    made.  Dr.    Whiting's    teaching    experience   has 

enabled  him  to  devise  means  for  overcoming  common  errors  in  applying 
bandages. 

i2mo  of  151  pages,  with  117  illustrations.  By  A,  D.  Whiting,  M.  D.,  Instructor  in 
Surgery  at  the  University  of  Pennsylvania.  Cloth,  Ji.«5  net. 


14  SAUNDERS'    BOOKS  ON 

American  Illustrated  Dictionary   ^ew  (Sth)  Edition 

The  American  Illustrated  Medical  Dictionary.  With 
tables  of  Arteries,  Muscles,  Nerves,  Veins,  etc.  \  of  Bacilli 
Bacteria,  etc.  ;  Eponymic  Tables  of  Diseases,  Operations, 
Stains,  Tests,  etc.  By  W.  A.  Newman  Dorland,  M.  D. 
Large  octavo,  1 137  pages.  Flexible  leather,  $4.50  net;  with 
thumb  index,  $5.00  net. 

Howard    A.    Kelly,  M.  D.,    Professor  of   Gynecology,  Johns  Hopkins 
"Dr.  Borland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of 
such  convenient  size.     No  errors  have  been  found  in  my  use  of  it." 

Golebiewski  and  Bailey's  Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 
ByDn.  Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions, 
by  Pearce  Bailey,  M.D.  Cloth,  $4.00  net.  /;/  Saunders^ 
Hand- Atlas  Series. 

Helferich  and  Blood^ood  on  Fractures 

Atlas  and  Epitome  of  Traumatic  hractures  and  Dislo- 
cations. By  Prof.  Dr.  H.  Helferich,  o:^  Greifswald,  Prussia. 
Edited,  with  additions,  by  Joseph  C.  Bloodoood,  M.D.,  Asso- 
ciate  in  Surgery,  Johns  Hopkins  University,  Baltimore.  216 
colored  figures  on  64  lithographic  plates,  190  text-cuts,  and 
353  pages  of  text.   Cloth,  S300  net.  ///  Saunders^  Auas  Series, 

Sultan  and  Coley  on  Abdominal  Hernias 

Atlas  and  Epitome  of  .abdominal  Hernias.  By  Pr.  Dr. 
G.  Sultan,  of  Gottingen.  Edited,  with  additions,  by  Wm. 
B.  Coley,  M.D.  Cloth,  ^3.00  net.  In  Saunders''  Hand- Atla^ 
Series. 

Fenger  Memorial  Volumes 

Collected  Works  of  Christian  Fencer,  M.  D. 
Edited  by  Ludwig  Hektoen,  M.  D.,  Professor  of  Pathol- 
ogy, Rush  Medical  College,  Chicago.  Two  octavos  of  525 
pages  each.     Per  set:   Cloth,  $15.00  net. 

Zuckerkandl  and  DaCosta's  Surgery  ^^^^^on 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O. 
Zuckerkandl,  of  Vienna.  Edited,  with  additions,  by  J. 
Chalmers  DaCosta,  M.  D.,  Samuel  D.  Gross  Professor  of 
Surgery,  Jefferson  Medical  College,  Philadelphia.  40  col- 
ored plates,  278  text-cuts,  and  410  pages  of  text.  Cloth, 
1 3. 50  net.     In  Saunders'  Atlas  Series. 


SURGERY   AND  ANATOMY  15 

Martin's  Essentials  of  Surgery     7th  Edwon 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Sur- 
gical Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  des- 
cription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  Martin,  A.  M.,  M.  D.,  Professor  of  Clinical  Surgery, 
University  of  Pennsylvania,  etc.  Crown  octavo,  338  pages,  illus- 
trated. With  an  Appendix  on  Antiseptic  Surgery,  etc.  Cloth,  $1.25 
net.    In  Saunders'  Question  Compends. 

Metheny's  Dissection  Methods 

Dissection  Methods  and  Guide.  Octavo  of  131  pages,  illustrated. 
By  David  Gregg  Metheny,  M.  D.,  L.R.  C.  P.,  L.  R.  C.  S.  (Edin.), 
L.  F.  P.  S.  (Glas.  ),  Associate  in  Anatomy  at  Jefferson  Medical  College, 
Philadelphia.     Cloth,  I1.25  net. 

American  Pocket  Dictionary         ^^^  ^^^^  j.ditio.„. 

The  American  Pocket  Medical  Dictionary.  Edited  by  VV.  A. 
Newman  Dorland,  A.M.,  M.D.  693  pages.  Full  leather,  limp,  with 
gold  edges,  ^1.25  net;  with  patent  thumb  index,  ^1.50  net. 

Bryan's  Surgery 

Principles  of  Surgery.  By  W.  A.  Bryan,  M.  D.,  Professor  of 
Surgery  and  Clinical  Surgery  at  Vanderbilt  University,  Nashville. 
Octavo  of  667  pages,  with  224  original  illustrations.     Cloth,  ;5S4.oo  net. 

Dr.  Bryan  here  discredits  many  fallacious  ideas,  giving  you  facts  instead.  He 
shows  you  in  a  most  practical  way  the  relations  between  surgical  pathology  and 
the  resultant  symptomatolgoy,  and  points  out  the  influence  such  information  has  on 
treatment. 

Meyer  €s  Schmieden's  Bier's  Hyperemic  Treatment 

Second  Edition 

Bier's  Hyperemic  Treatment  in  Surgery,  Medicine,  and  the  Special- 
ties. By  Willy  Meyer,  M.  D.,  Professor  of  Surgery,  New  York  Post- 
Graduate  Medical  School  and  Hospital;  and  Prof.  Dr.  Victor  Schmie- 
den, Assistant  to  Professor  Bier,  University  of  Berlin,  Germany.  Octavo 
of  280  pages,  illustrated.     Cloth,  $3- 00  net. 

Morris'  Dawn  of  the  Fourth  Era  in  Surgery 

Dawn  of  the  Fourth  Era  in  Surgery  and  Other  Articles. 
By  Robert  T.  Morris,  M.  D.,  Professor  of  Surgery,  New  York  Post- 
Graduate  Medical  School  and  Hospital,  i2mo  of  145  pages,  illustrated. 
J! 1. 25  net. 


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